The Madness of China's Mental Health System

One of the country's leading activists and health advocates explains the tragic irony of mental health in China today: Many who need treatment won't get it, while many who don't are forced into treatment to silence political dissent.

According to a 2009 article in the British medical journal The Lancet, as many as 17.5 percent of China's adult population may suffer from some kind of mental illness. Yet mental health remains a vexing, and in some cases taboo, topic in China. The trauma and reversals of recent decades, from the Cultural Revolution to the current all-consuming drive for wealth, from shifting family structures to the migration of millions of people each year from villages to cities to find work, all have put invisible strains on the people living through these vast changes. Some recent headlines from the past year indicate that untreated mental illness may be becoming a more acute problem in China: a series of grisly attacks by middle-age men on school children, some of them deadly, caused a great public panic. The suicides of several young workers at a factory in southern China assembling iPhones likewise raised questions about where migrants (most workers are living far from home) can turn to for emotional support in difficult times.

Meanwhile, even as many people who need medical attention are unable to receive help -- either because it is too costly or because of the great social stigma attached -- there are others who are healthy but are labeled "mentally ill" by authorities seeking a reason to detain them in mental-health hospitals, as the New York Times recently documented. One man mentioned in the article, for instance, is 54-year-old Xu Lindong, who was forced to spend six and a half years in mental hospitals and subjected to 54 electric-shock treatments following a land dispute. (A recent New Yorker article explored the interest -- and confusion -- among some in China regarding the ideas of Sigmund Freud.) This is the tragic irony of mental health in China today: Many whose lives could be improved will never receive medical attention, and many who don't need it are held in confinement in the name of medicine.

In this context, I would like to offer my own personal story. I was trained in medicine in the 1980s and subsequently worked for a government health institute and then for a private NGO dedicated to AIDS awareness, which brought me into contact with marginalized populations and stigmatized people in China, including those wrongly labeled as mentally ill. I have seen people sent to mental hospitals for being gay, for domestic disputes, and for political dissent.

I was born in 1963 and grew up in a small town in Anhui province. The first person I remember being described as mentally ill was my father. He was a police officer in the 1950s; he found his work very hard to do, and by the time he left his job in the late 1950s, he hated politics. During the Cultural Revolution, which began in 1966 and lasted for 10 years, he spent time in a labor camp. There were two words people used during my childhood to describe people with a mental illness: One was fengzi, which means a dangerous person without restraint or a conscience. The other was naozi shou ciji, which means someone with a mind broken by pain or stress. That was what they said of my father. He was not ever formally diagnosed because there was very little understanding of mental health at that time in China; under Mao Zedong, it was seen as a sign of weakness. I think my father's problem was not mental illness, but instead that he had an independent mind. He read a lot and thought differently about the world. In the 1970s, people often used the label of mental illness for people like that.

In secondary school, I had to decide between focusing on science or on politics and literature. My father said to me, "If you study politics and literature, you will have to lie. But if you study science, it has nothing to do with politics." He also made the argument: "Even if you are put in prison, the police will be kinder to you if you are a doctor." After the Cultural Revolution, many families encouraged their children to study science, engineering, and medicine. That is how I came to attend Shanghai First Medical College, which I entered in 1981.

During that time, interest in Western notions of mental illness grew quickly. The 1980s were a period of relative openness in China, when foreign ideas on everything from art to politics to medicine to environmentalism began to flood into China. During the Cultural Revolution, psychology was considered a "pseudo-science." But after 1986, I remember a lot of lectures at university on psychology and psychoanalysis. In 1987, I helped to translate two chapters from an English-language book about psychological counseling and crisis intervention. I graduated in 1988 and moved to Beijing, where I got a job as a health researcher for the National Health Education Institute, which is part of the Ministry of Health. I remember in 1989 when the ministry established the first suicide-prevention hotline in Beijing. By no means did Chinese health professionals understand or accept mental health issues the way Westerners did in those years. Still, the trend was clearly toward a more progressive understanding, focused on improving the lives of patients.

In 1995, I founded one of China's first NGOs, the Aizhixing Institute of Health Education, with a mission of increasing awareness, treatment, and prevention efforts for HIV/AIDS in China. My work brought me into contact with some of the sub-populations most affected by the disease, including gays and lesbians, drug users, and sex workers. All suffer great social stigma in China. Until 2000, being gay was technically classified as a mental illness in China, but gay people still suffer extraordinary discrimination. I remember in 1997, when a 30-something lesbian woman attended a meeting held by Aizhixing on lesbian rights. She was quick and energetic. She told me her family had sent her to a mental hospital for six months because she was not married and they thought something must be wrong. She asked me, "Was this the right approach?" Of course I told her it was not. We talked about the confusion on the hushed topic of sexuality and mental illness.

In the past 10 years, I believe that an increasing number of healthy people have been hospitalized as "mentally ill." This is troubling to me. The trend began with the government crackdown on the dissident religious group Falun Gong, which was banned in 1999. The authorities labeled members of the group as mentally ill -- and therefore an alleged threat to social stability -- and used that as pretense to confine them. When the government saw that approach could be useful, it expanded the strategy to target a broad swath of political dissidents and petitioners.

Because of my own work on the controversial topic of AIDS, I have been detained three times, and in May 2010 I left China because of increasing political pressure. I have crossed paths with many activists and NGO leaders in similar positions; we all want to improve the lives of people in China, but the government finds our work threatening. We did not form organizations to be against the Chinese government, but we are sometimes considered by the officials to be dissidents or troublemakers. One example is Zhou Yi Juan, a Buddhist nun who in 2005 organized a memorial in Tiananmen Square to the victims of the June 4, 1989, massacre. Afterward, she was forced to enter a mental hospital for psychiatric treatment. In 2007, Aizhixing supported her with a fellowship to write a memoir about this experience; two years later, she took legal action and sued the hospital. I believe that these cases should be known more widely.

Today in Beijing three government branches operate mental hospitals: the health department, the police department, and the civil affairs department. This is troubling evidence that mental health is not seen as a medical issue, as it should be, but as a matter of social stability and a concern of law enforcement. This attitude leads to abuses, and there is no appeal process for people like Zhou Yi Juan. In Zhejiang province, an official document dated March 23, 2010, and published online details the collaboration between the local police and health departments on mental health, which is wrongly described as first and foremost a social stability issue. In a troubling return to the climate of suspicion my parents experienced during the Cultural Revolution, neighbors in Zhejiang are encouraged to report on each other if they suspect mental illness.

These examples represent only a small glimpse of the vast confusion over mental health in China. These are tragedies the world should know about. The impulse to hide the problems is the worst approach.

Getty Images/China Photos


Don't Forget Gaza

Amid the political turmoil engulfing the Arab world, there's one overlooked problem spot that could easily explode again.

Two years have just passed since Israel's Operation Cast Lead, which aimed to stop rocket fire from Gaza and arms imports into the territory. Since then, only the efforts of international activists to break the Israeli blockade of Gaza in 2010, most famously the Turkish boat Mavi Marmara in May 2010, created any urgency to address the plight of the impoverished Palestinian territory. Those events did lead Israel's security cabinet, under concerted international pressure, to announce a set of measures to ease its land blockade, though a coalition of international humanitarian NGOs has criticized the move as inadequate. Rocket fire from Gaza into southern Israel and its communities has also risen alarmingly over the past few weeks. Faced with banner headlines about the "Palestine Papers," the people's uprising in Tunisia, protests in Egypt, and escalating political tensions in Lebanon, Western observers are hardly focused on Gaza under Hamas rule. But the recent rise in hostilities between the Israeli military and Gaza's militants as well as the plight of Gazans themselves should be a timely reminder of the danger of ignoring the Gaza situation for too long.

Before Hamas forcefully took over the territory in June 2007, I had lived and worked in Gaza as an official for the United Nations. On my recent trip there to assess current socioeconomic conditions and Hamas's efforts at governance and institution-building, I found that Gaza had changed dramatically in the intervening years, and not necessarily for the better.

First, Israel's partial lifting of the blockade in the summer of 2010 has not noticeably improved the lives of most of Gaza's residents. According to international NGOs and the United Nations, more than 80 percent of the population still depends on international aid; the unemployment rate hovers around 45 percent, one of the world's highest. Nearly 80 percent of the homes and businesses that were destroyed in Operation Cast Lead have not been rebuilt, and 90 percent of the water supply is unsuitable for drinking. Although shops are well stocked with food and consumer goods, very few Gazans can afford anything but the basics. Meanwhile, according to local economists and bankers in Gaza, the tunnel economy, a direct beneficiary of the blockade, is still estimated to be generating between $150 million to $180 million per year, or half a million dollars a day, for the Hamas government in Gaza.

Second, Hamas is too entrenched in Gaza to be forced out by anyone, including the Palestinian Authority (PA). Following Hamas's forced takeover of the territory in June 2007, the militant group has been busy consolidating and institutionalizing its governing control. The PA has unwittingly helped Hamas by instructing its 77,000 personnel in Gaza not to show up for work, while still paying their salaries. The result is that, through trial and error, the Hamas government has established a relatively efficient and cost-effective public administration structure. Hamas-run ministries are now functioning, backed up by 20,000 civil servants and 15,000 well-organized and disciplined police and internal security personnel. Very few people in Gaza, according to my conversations there, believe that Hamas control can be challenged. In fact, the main criticism of Hamas is its reflex to tighten control on all aspects of Gazans' lives.

In consolidating its rule, the Hamas government has embarked on a fairly ambitious infrastructure development program, which includes the construction of 61 kilometers of asphalt-paved roads, a 245-km water network, and a 125-km sewage disposal network. As several senior Hamas government officials with whom I spoke acknowledge, much more infrastructure development is urgently needed, including the building of some 140 schools, medical clinics, and thousands of homes. New water, sewage, sanitation, and electricity networks are also required.

While the Hamas government has faced cash squeezes in meeting its $25 million monthly bill, most notably in the first half of 2010, it has been amply supported by the broader Hamas movement, donations from Iran -- which is widely believed to be providing the bulk of donations -- and the Muslim Brotherhood international. Other foreign governments, including those of Libya and Algeria, as well as Arab charitable organizations, mainly from the Persian Gulf states, also provide regular funding. The bottom line is that Hamas is no more likely to run out of money than is the Palestinian Authority in Ramallah.

Third, as Hamas balances the practicalities of paving roads and building sewers with the ideology of resistance, there are clear differences within the movement on its future direction in Gaza. For pragmatists, the task is good governance and ensuring stability and security to consolidate its rule in Gaza; for those intent on pursuing resistance, the fear is that the burdens of governance will continue to blunt the movement's raison d'être: armed struggle against the Israeli occupation. For now, the pragmatists seem to have the upper hand: Under Israeli threats of a renewed large-scale military operation in Gaza, the movement is working to halt the rocket fire from Gaza into Israel, which has risen sharply in the past few weeks. It has also sought to recruit respected and qualified independent figures to serve in the government, people who have been critical of Hamas but would strengthen the competence of its administration. What is clear to many analysts in Gaza, including some senior figures in Hamas, is that it cannot effectively rule the territory without ensuring stability and security. For that reason, the movement will have to choose between the two -- armed resistance or good, effective governance.

Equally clear is that cooperation between the Palestinian Authority and Hamas in Gaza is urgently needed. Gaza's citizens, while less supportive of Hamas rule today than in 2007, largely blame Israel and the Fatah-dominated Palestinian Authority for their blighted existence. Independent Palestinian figures and ordinary Gazans told me repeatedly that they believed the Palestinian Authority had forgotten them.

Senior Hamas representatives stated their readiness to cooperate with Ramallah. Most recognize that without greater cooperation with the Palestinian Authority and through it, the outside world, the relative isolation of the Hamas government will continue to undermine its genuine efforts to govern. Greater long-term cooperation with the West Bank may also encourage the pragmatists within Hamas to persuade the movement in Gaza and the exiled leadership in Damascus to concentrate their energies on political dialogue and governance, not rockets and suicide bombs.

There is some reason to hope: Hamas and the PA have in some cases sought to cooperate, albeit out of necessity and with some difficulty. In June 2010, the education ministries of the PA and Hamas cooperated to enable some 87,000 secondary-school students to sit simultaneous final exams in Gaza and the West Bank. After nearly six months of talks in the first half of 2010, the two sides collaborated to open seven sports clubs in Gaza, directly benefiting thousands of young people; and more recently, in early November the PA worked with Hamas to arrange for some 5,000 Gazans to make the pilgrimage to Mecca for the first time in three years. (They have had less success, however, in agreeing on how best to supply electricity and medicine to suffering Gazans.)

Salam Fayyad, the technocratic Palestinian Authority prime minister, could be a powerful unifying force. He has described the blockade of Gaza as "wrong and wrongheaded," but has also been criticized by those in Gaza who feel that he has not done enough to alleviate their plight. Some Hamas representatives go as far as to accuse him of being America's man and colluding with the Israelis. There are, however, at least some in Gaza, including senior Hamas representatives, who think that Fayyad can deliver further cooperation and that if he decides to work on this, it will have a positive impact on relations between him and Hamas as well as on ordinary people.

One point on which all Gazans can agree -- be they community figures, independents, and representatives of Fatah or Hamas -- is that the Israeli siege has to end. It has proved spectacularly counterproductive in its aim of weakening Hamas rule in Gaza. Instead, it has guaranteed Hamas rule. It is time to try a different approach before the current strategy leads to more suffering and Gaza's permanent division from the West Bank -- and with that, the fading prospect of a viable Palestinian state alongside a secure Israel.