顶尖神探解开中国养老护理缺口之谜

同志好! Before I begin our investigation into this healthcare whodunit, a couple housekeeping items: First, I have created a mirror site www.chinaseniorliving.org as the Chinese government blocks my host, WordPress, and therefore my formal CSL site www.chinaseniorliving.com is unavailable to my colleagues, clients and constituents in China. Many Mainlanders have asked for access to my blog so I decided to create a site accessible to them.  The format is a little different but the content is identical. Second, the inspiration for this blog is twofold: on one hand is my interest in wanting to write a follow-up to my blog posting #5 Farewell my migrant healthcare worker but haven’t gotten around to it. In some way, this piece is a good echo as I address the general industry wide human resource issue albeit from a different perspective. On the other hand, I want to promote real answers for actual industry problems and not just ask rhetorical questions. Well, in due form, here is a solution to one of the big challenges we face….put your gumshoes on….the game is afoot![1]

I sat down with the venerable Detective Charlie Chan on the piers of Xiamen last week to discuss a mystery that has been frustrating the senior living industry in China of late, namely the dearth of adequately trained geriatric staff. Lucky to have such a moment with the brilliant detective, I wasted no time, “Detective, may I ask that you impart some of your investigatory powers to my quandary?”

Charlie Chan, sitting across from me, supremely confident in his white linen suit and Panama straw hat, smiles and responds, “Grateful to assist any way, Ke Zong.”

I nod in appreciative supplication as Chan addresses me respectfully as Chairman Cole. I begin, “Imagine, if you will Detective, a human resources paradise; a separate reality, a parallel universe, linguistically and culturally identical to China yet with a social welfare system advanced by, say, 25 years. Such a Shangri-La might offer “crystal ball” possibilities, a peek into the future if you will; experienced geriatric nurses, a proven and culturally acceptable business model for senior living enterprises to mention just a few, no? We in the senior living business here in China are in dire need of such a vision.”

Detective Chan considers my statement carefully and ponders my dilemma. Stroking his short dark beard, he cocks his head slightly and gazes out from the shores of Fujian Province and over the 180 kilometer-wide Formosa Strait as a salty, sub-tropical air rushes over the pier. Charlie Chan, eyes focused on the horizon, responds cryptically as if speaking to the breeze, “Humble to suggest…..foolish to seek fortune when real treasure hiding under nose……”

After a brief moment, Chan slowly turns his head. His almond shaped eyes penetrate; he stares at me silently.  I am suddenly aware of the gravity of his proposition, he has given me a clue and it has implications…..

Briefly….Charlie Chan

Early last century a wholly adorable detective persona was created by Earl Derr Biggers called Charlie Chan.  He was loosely based on Honolulu detective Chang Apana; Biggers conceived of the benevolent and heroic Chan as an alternative to early 20^th century Yellow Peril stereotypes, such as villains like Fu Manchu so prevalent at the time. Chan first appeared in Biggers’ novels, but went on to be featured in a number of media including, believe it or not, comic books. Nearly four dozen films (47 to be exact) featuring Charlie Chan have been made, beginning in 1926. If you have seen any of the Chan pictures, he immediately reminds one of the more modern private eye incarnations such as the equally endearing and humble, yet mercilessly relentless, Detective Columbo; polite, inquisitive and always vexing to the guilty. Nearly as legendary as his finely honed detective skills was Charlie Chan’s ability to pepper his dialogue with aphorisms delightfully appropriate to the moment. Whether he was tangled up in a dangerous situation or enjoying a quiet interlude with one of his many children, Mr. Chan always had a timely truth poised on the tip of his trenchant tongue.

The character was at first portrayed by Asian actors, and the films (3 of them) met with little success. In 1931, the Fox Film Corporation cast Swedish actor Warner Oland (of Shanghai Express fame and Blog Post #6…) as Chan in Charlie Chan Carries On; the film was a box office blockbuster, and Fox went on to produce 15 more Chan films with Oland in the title role. After Oland’s death, American actor Sidney Toler was cast as Chan; Toler made 22 Chan films, first for Fox and then for Monogram Studios. After Toler’s death, six more films were made starring Roland Winters.

The Crime Scene

A few weeks ago, eager to pursue Chan’s hint that a possible solution involved a place on the horizon, I flew from Beijing south and across that 180 kilometer-wide, cerulean Formosa Strait to visit the tiny island of Taiwan, on an investigation to a place I lived for nearly 5 years in the 1970’s. Early one morning I boarded Air China flight 185, as if I had a search warrant in hand armed with the fervor of CPC police in pursuit of political dissidents.

I was once told that if you really want to know a city in which you are a visitor, wake up early and walk.  Watching how a city gets out of bed and starts its day reveals its heart and soul. So, on my first morning back in Taipei, in due fashion, I woke up at 5:30am and began to walk around….up and down Zhongshan North Boulevard, under ribbons of dizzy, soaring freeway overpasses….as the sanitation trucks, operated by men and women laughing at each other’s jokes, wrestled with foul smelling bags of rotten food. The street sweepers whistled while shop owners washed and scrubbed their sidewalks clean of the night’s grit. This may seem a little Disney-like (nope, no chorus line erupted), but in large part it is true, Taipei has grown up and is a pleasant place at that hour in the morning. Now, at 6:30am after the City’s first cup of jasmine tea, this day dream ends and things do of course change. Despite the charm of an early Taipei morning, its days are oppressively hot; the humidity dominates, the pollution asphyxiates and the congestion incarcerates.

In the early 1970’s Taiwan struggled; citizens had few freedoms, frequently censored media, and a burgeoning manufacturing center of goods deemed cheap knockoffs by most. But time and prosperity cure many things and today the island stands in stark contrast to what it was back then.  Contemporary Taiwan is a thoroughly modern, first world economy and an Asian center for technological innovation.  Its citizens enjoy rich civil rights (wait…littering, spitting and other objectionable, antisocial behavior has been outlawed and infractions are punished with near Singaporean-like severity. The result is, however, notably clean streets and subways) and, comparatively speaking, have a comfortable standard of living. The island has a population of just about 23 million, roughly the size of Beijing; Taiwan’s over-65 demographic is 2.5 million with an average life expectancy of nearly 80 years. Sure, Taiwan is little, but remember what Chan says about packaging:

“Humbly suggest not to judge wine by bottle” Charlie Chan’s Greatest Case

Thirty five years ago, Taiwan was governed by the authoritative and strong armed Kuomingtang, Chiang Kai-shek’s Nationalist Party which fled from mainland China in 1949 having essentially lost its battle against Mao’s communist party. Today, the island is a multi-party democracy with an opposition candidate having won the presidential election for the first time on March 18, 2000. The peaceful transfer of power from the Kuomintang to the Democratic Progressive Party validated Taiwan’s democratic political system. To my mind, Taiwan’s social and political success is evidence of what an emerging pluralistic democracy can achieve; witness: the disproportionately large effect on the world economy which the small Chinese population of Taiwan has had. And while the United States can rightfully take some credit for providing a safe haven for such prosperity to flourish, the Taiwanese were/are driven and continue to be eager for even greater successes.

 The Forensic Evidence

All good mysteries are founded and solved on the discovery and development of clues. Clues are, of course, developed based on a preponderance of evidence, intuition for the nature of the crime and an insight into the motivation of the perpetrator. Well, we don’t really have a crime here nor do we have a culprit or I should say, without proof as of yet, the alleged guilty party. But since those of you who are reading this have likely read my previous blogs, you appreciate the liberties I take with story lines; I am sure you get it.

My clues here are based on the evidence I found at the CCRC’s I visited in Taiwan and the interrogation (again, my liberties) of a unique industry professional. A photo diary of these facilities can be found on my box.net account, download here:Blog Post #7 Photo Diary. The questioning of my witness follows the presentation of the evidence. At the end of the story I set forth my final argument and hope you are as convinced as I.

Clue #1: My first investigation turned up Chang Gung Health and Culture Village, a large CCRC 30 minutes from downtown Taipei and 15 minutes to the (new) airport, Chiang Kai-Shek International airport, in Taoyuan. Chang Gung is the brain child of one of Taiwan’s wealthiest and most philanthropic minded entrepreneurs, Mr. Yung-Ching Wang. In its present configuration the facility, built in 2005, is comprised of 700 independent and assisted living units and a 250 unit nursing facility. The facility is about 75% occupied. I believe the reason for the low occupancy is that the primary access road has been under construction for about a year and a half; it is an unpleasant journey and must kill the sales process before it even begins. The entire land area at Chang Gung will ultimately be built out with another 15 buildings with a total of 3,000 senior living units; to be sure, an impressive and large facility.

Chang Gung is owned by the Chang Gung system of hospitals and like the hospitals it is a private facility. Naturally, the facility has a direct agreement with the Chang Gung hospital (located 3 kilometers from the CCRC) to provide preferential, emergency health care to the residents of the CCRC and there are a number of ambulances to quickly shuttle residents if need be.

By Taiwan standards, Chang Gung is affordable. The facility leases rooms based on annual rental. There are two unit sizes, a 22 ping[2] unit and a 14 ping unit. These units rent for NT26,000[3] per month and NT18,000 per month with a surcharge of NT5,000 per month for an additional person. In order to rent a unit, a deposit of 12 months is required.  A package deal is available which includes meals and activities (an extra NT4,500). Chang Gung has an assisted living program which essentially includes 2 hours of social worker or nursing attention on a daily basis. This program costs NT10,000 per month.

What strikes me as important about Chang Gung isn’t their facility at all but the quality of their staff. Each nurse and every social worker hold university degrees in their fields and special certificates for geriatric care. These geriatric care certificates are not bestowed as a result of a quick 20 hours of classroom work but require no less than 8 months of both classroom study and clinical experience. Further, Chang Gung’s nurses are all members of a nurse union or other labor union which requires maintenance of professional standards among their rank and file. These unions also lobby Taiwan’s legislature to advance the status and financial security of nursing in Taiwan. If nothing else this evidence is an undeniable clue to the fact that nursing is deemed an important job and one that has growing status in Taiwan society.

Clue #2: Later that morning I got back into the mini bus, generously provided by Bruce Liu of 55 Tone, and headed north to the seaside community of Sinchi, about an hour from Taipei. We arrived at Suan Lien Elder Home: a 250 room CCRC owned and administered by the Presbyterian Church of Taiwan (this CCRC is a public facility and not exclusively for those of the Presbyterian faith). For a CCRC it is small, but the hardware at Suan Lien, which was built in 2000, is well maintained. I would grade the buildings and interior highly.

Again, the impressive thing here isn’t the facility although like Chang Gung it is attractive, many rooms have ocean views. Suan Lien’s pricing is not much different from Chang Gung; the differences that exist amount to a slightly higher initial deposit and a special medical deposit for dementia patients (the term memory care has not yet come to Asia). The dementia care wing at Suan Lien is the best I have seen to date in Asia (ex. Japan) and is based on what they refer to as “unit care”. The Suan Lien is 100% full and it has a waiting list of over 1,000 people. It is regarded as one of the best retirement homes on Taiwan. Why? Simple, the quality of the staff and the support of an organization that is trusted by the Taiwanese to deliver care without regard to profit. Even the Taiwan government has taken notice; it provides Suan Lien with a subsidy of over NT5 million to augment their care program. Here is the grand finale; Suan Lien’s budget has a dedicated line item to allocate 10% of their beds to low income persons[4]. Consider the evidence here: the presence of faith-based senior living organizations is often a sign of a higher commitment to care and can be an indication of superior care quality. But to add to this government financial support and self-imposed low income beds….I find this to be a subtle but strong clue of an advanced industry. As Chan would say:

“Little things tell big story” Charlie Chan in London

Clue #3: I lingered at Suan Lien a bit too long and my host, Bruce Liu, had to shuffle my team and me back into our transport and rush us to our last stop of the day: Jen Shi Citizens Rest Home. Jen Shi is located back near Taipei in a suburb called Dam Shui. This facility, with only 122 beds, is the smallest I saw while in Taipei and the oldest, having been built in 1960. The original facility was torn down in 2002 and rebuilt into its current configuration. The facility operates today at 92% occupancy.

Again, pricing at Jen Shi is not meaningfully different and I found the staff of equal if not better quality than both Chang Gung and Suan Lien. What struck me about Jen Shi was the facility manager, Chen Wei-Ping. Wei Ping is a woman, I estimate in her early forties, and has been the manager of Jen Shi for 10 years. Always smiling, she has a friendly but commanding personality and highly sure of herself. As we toured the facility, she clearly has the admiration of her staff as they all paid respectful notice to her in passing. Moreover, each resident we met broke into open conversation with her almost as if they were finishing a chat started just a few minutes before I arrived. Wei Ping is clearly engaged with her facility in a manner I have not seen yet in Asia; she is fully immersed with her residents and staff. She lives and breathes it.

While we were walking the halls I had the chance to ask her about care standards. She reported that Taiwan’s Ministry of the Interior created the Bureau of Social Welfare nearly 8 years ago. This Bureau is charged with the inspection and enforcement of many different social welfare functions in Taiwan, including retirement homes. Every 3^rd year, they do a comprehensive inspection of every senior living facility in Taiwan, its care program, staff credentials and resident interviews. Ah, my last clue: State enforcement and management of standards in any business is irrefutable evidence of an advanced or at least developing industry.

The Smoking Gun

Late on my second day in Taipei, I interrogated my primary witness, Dr. Shyh-Dye Lee, M.D., a valuable informant: he is the founder of Taiwan’s Graduate Institute of Long Term Care, a professor at the National Taipei University of Nursing and Health Sciences and the current Chairman of the LTC Association, founded in 1994.

Professor Lee came to the meeting in what I came to learn during the course of our chat his typical serious mood; I was lucky to meet with the Professor.  He is a solemn person and discusses the status of senior living in Taiwan in a humorless manner as if preaching to the unfaithful; like Chen Wei Ping, Professor Lee is driven…dedicated to a selfless vocation of improving the status and quality of senior care to the Taiwanese elderly; he is a jewel in the crown for Taiwan’s aged care industry.  During the course of my examination, I was struck by his mastery of aged healthcare; using vocabulary such as mobility indices, tertiary preventive care programs, and non-pharmacological interventions for dementia; the Professor is unimpressed with fancy facilities and high-end amenities, he is simply, wholly absorbed with the advancement of caring.

Professor Lee struggles with trying to help Taiwan evolve with what the West experienced in the 1990’s namely, the “Culture Change Movement”. His single most important mission? Attempting to advance Taiwan’s understanding and practice of gerontology from a medical model of care to a philosophy of wellness….a noble calling, indeed.

My time with Professor Lee was invaluable and proved to me that he has no Mainland counterpart. He has been to China and laments the “real estate cum service model” trap to which many elderly are falling prey. When asked to point out aged care differences between Taiwan and China, he holds forth with encyclopedic knowledge of Taiwan’s geriatric care industry regulations such as Senior Citizens Welfare Living Allowance Provisional Act[5], which provided all those over the age of 65 with additional state funds to be used for aged care if required. Legislation such as this clearly sets Taiwan above and beyond China’s present status and is a model that should be studied. I am immediately reminded again of Chan’s wisdom when thinking of Professor Lee’s functional lack of a peer in China:

“Man who improve house before building foundation, apt to run into very much trouble” The Feathered Serpent

I don’t want to overstate my case here. In all reality there may be an aged care specialist or two whose breath of experience, understanding and drive is a good match with the Professor’s; after all, I have not undertaken a census of all geriatric care professionals in China. However, I doubt it, and even if there are, I am willing to wager that Professor Lee is certainly not unique in Taiwan; there are plenty of experienced clinical geriatricians on the island all of whom speak Mandarin, are ethnic Chinese and thus represent a precious pool of human resources.

Mystery Solved, Case Closed!

In sum, the strategic advantages offered by Taiwanese skilled labor have been wholly overlooked by senior living companies looking to gain a foothold in the China market to date. I have 3 reasons to believe that Taiwan serves as a likely source, if not the leading provider, of senior living, nursing and LTC human resources (not to mention a model for building and care standards) for the near future:

1)     Taiwan is nearly linguistically identical to mainland China; at most there is a slight accent that separates them, 

2) Taiwan and China are culturally and ethnically very similar if not indistinguishable from each other, and

3) In a social welfare and a public health context, Taiwan is no less than 25 years ahead of China.

I don’t mean to suggest that Taiwanese skilled labor offers a panacea for China’s senior living industry or that the industry’s structure is a jig for China’s; in fact, my point is far from this notion. To wit, the Chinese love affair with western brands will certainly preclude this from ever taking place, however misplaced this infatuation may be. My point is better understood through another of Detective Chan’s aphorisms:

“Good tools shorten labor” Charlie Chan at the Circus

What the Taiwanese offer is simply a “plug and play” solution to certain temporary management /training roles in a CCRC or other geriatric service facility. Taiwanese geriatric nurses have the care skills, the language ability and their culture is a match; there are no cross-eyed stares, instead, understanding is seamless and without the problematic filter of interpretation. Now, the concept of the mainland using Taiwanese labor to improve their knowledge base is not a new phenomenon, in fact there are thousands of Taiwanese working in China; after all the pay is good and they have an edge.

There are shortcomings however. Namely, this relationship doesn’t last long; once the Chinese master the Taiwanese’s skills, the liaison is usually over as the imported labor is usually significantly more expensive. Also, there are some day to day sensitivities that need to be addressed with hands on management and understanding. These differences, borne out of the complex political relationship between Taiwan and China, should be viewed and treated like diversities and then won’t prove fatal; think of these generally as the rivalry that occurs between siblings; one bigger and stronger the other smaller but smarter.

“If strength were all, tiger would not fear scorpion” Charlie Chan’s Secret

In my last blog posting, All aboard!….this the China CCRC Express, I set forth the “FIRE!…. Aim….Ready…..approach to geriatric care development in China. There are those in the CSL industry today, the true players that live and work there, who are setting plans to construct training centers and proceeding along an “organic” method of building experienced teams of geriatric technicians. Ultimately, I am agnostic about this. On one hand I see the value of a home grown bench, if you will. On the other, I see it as an opportunity for endless frustration as undoubtedly such a valuable resource will be cherry picked mercilessly by the competition. At least temporarily, I tend to favor importing skilled labor over the expense of building a training facility and program. There will come a time for building training centers, I have no doubt, but in the meantime I will take my cue from Chan:

“Ideas planted too soon, often like seeds on winter ground – quickly die” The Sky Dragon

Not only am I the detective here but I am also judge, jury and executioner, after all this is my blog. So in closing, I want to address yet another often suggested solution for staffing which I have seen attempted a couple of times. Namely, this is the use of translators to interpret between a western company’s clinical experts, their managerial staff and local employees. Now, if we were talking about an assembly line production of widgets on a fast moving conveyor belt….the “inserting A into B and wrap with C”…type of job, and then I might wholly support the translator method of proceeding.

But we aren’t a production line, gerontology and geriatrics are the “fine medical arts”. We are talking about caring for frail, elderly Chinese persons who were born before the revolution and are likely slightly unmoored by the notion of living in a facility not to mention their apprehension with modern Chinese society in general. Now then, introduce into this mix John Q. Manager who has been in China for 6 months, standing next to his translator who is hastily trying to communicate western aged care concepts, predicated on a western government regulated delivery system of care, to a group of nurses educated in the Chinese healthcare system. While the two parties argue and misunderstand one another, the patient wanes.

I don’t see this as a very practical solution. And while this doesn’t preclude western companies from participating in the CSL industry, it does mean their approach must be nothing less than Chinese and not one predicated on what is done in Omaha, Nebraska.

Ah, so….the solution to the case the missing Chinese geriatrician is a bit of a trick question…they aren’t really missing today, they are just all in Taiwan.

I rest my case. 

*******

I hadn’t been back in Beijing for a day when I happened upon Detective Chan while out and about in the Guo Mao. Eager to report on my trip, I intercepted Chan as he walked towards the CCTV tower.

“Detective Chan!” I called out, “I’ve just returned from Taiwan I found some extraordinary information!”

“Ah, Ke Zong, grateful for surprise encounter!” Chan chirped as he shook my hand. The Detective leaned into me slightly and whispered, “Old police slogan: unusual thing always good clue.”

I smiled warmly and responded with a wink. “Elementary my dear Mr. Chan[6], Old police slogan is true. I think you helped me solve an important mystery!”

“Difficult problem have many solution, Ke Zong.” Chan counseled waving his index finger back and forth.

“Yes, I know, Detective. And this mystery likely has a few but you also once told me “All solutions to same problem not created equal.”

The Detective praised, “You learn fast, Ke Zong. It is good to see you back in Beijing!”

“Thank you Chan, It is good to see you again as well…..I have been meaning to ask your thoughts on another matter…regarding the operating model….”

Chan, sensing another mystery being placed at his feet, smiles as he turns to cross the street and cuts me off mid-sentence, “Always pleasant journey which ends among old friends, Ke Zong…..” Chan’s voice trailed off as he made his way into the cross walk.

Frantic to keep his attention, I interject, “But…..Detective, it won’t take but a min….”

But the sleuth is too swift and slides out into the street. Halfway to the other side Chan turns, lifts his straw hat and nods at me, “Must let student solve other mystery by self….humble Detective have important appointment with gerontologist” Chan reaches the curb as the lights change. Squadrons of motorbikes charge loudly into the intersection partially obscuring Chan. I catch a fleeting glimpse of the Detective’s white linen suit as he moves in the swarm of noonday foot traffic….watching as his hat appears once, bounces between heads, then disappearing into the crowd.

I want to thank Bruce Liu of 55 Tone and Miranda Liao of Hampton Hoerter China for their undaunted assistance in Taiwan.

为人民服务!

Footnotes:

1) Ok..ok, so this phrase was actually Sherlock Holmes and not Charlie Chan…forgive me…it sounded good when I wrote it.

2) The unit of measurement that a ping represents is equal to about 3.3 square meters. These units would therefore roughly equal to 650 sq.ft. And 415 sq. ft. respectively.

3) The conversion rate of NT to USD is 29:1.

4) I asked if the government financial support required the allocation of low income beds and they said no; it is self imposed.

5) Promulgated by Presidential order Hua Tsung (1) Yi Tzu no. 09100100580

6) Op. cit footnote #1.

同 志 好! “It took more than one man to change my name to Shanghai Lily,” purrs Marlene Dietrich in Josef von Sternberg’s film 1932 adaptation of Harry Hervey’s book Shanghai Express. She certainly has her well-manicured talons sunk into more men than she can count in this exotic far-Eastern, chiaroscuro-cinematographic adventure. Among her fellow passengers on the Shanghai Express are her disenchanted former fiancé, unshakable British medical officer Clive Brook; over-zealous missionary Lawrence Grant; dope smuggler Gustav von Seyffertitz; and enigmatic Eurasian businessman Warner Oland. Coincidently, Oland made frequent appearances in other China-themed movies, most notably as Charlie Chan, the benevolent and heroic Chinese detective based in Honolulu as well as a future movie character for this blog.

Join us at Retirement Living World China !!

As the train chugs through the more treacherous passages of war-torn China, Oland reveals himself as the leader of a rebel group, who plans to hold the passengers hostage to secure the release of his imprisoned constituents. In Boule de Suif fashion, Dietrich, who portrays a notorious “Chinese coaster” has remained sexually remote throughout the trip, gives herself to Oland to save the life of Brook, the man she truly loves. Directed by Josef von Sternberg at his most orgiastic (check out the long, lingering dissolves!), Shanghai Express is 80% style and 20% substance.

Tickets, please….

This blog posting is about China’s 3 largest and most visible geriatric care developments to date. I warn you in advance, this posting is painfully long but the information conveyed is important for those interested in senior living in China. Each of these projects has been in the market for at least 2 years and in one case nearly 5 years. I call them CCRC’s (continuing care retirement communities) because, well, that is what they set out to be and in some part that is what the developers have accomplished…or, better yet, are clearly struggling to accomplish.  One of these developments had the benefit of limited foreign assistance, the others did not. The one that did clearly benefited and consequently has the best aged-care program in China today. All are chugging along with common weaknesses and each has their strengths. In sum, it is a mixed bag and to the inexperienced eye (read: China senior living experience, not western senior living experience; I say this as nearly all western geriatric care practitioners who see their first China project immediately conclude that all China senior care is a train wreck) it might seem as if the idea of senior living in China is just on the wrong track. But it is early and the train hasn’t left the station, at least not just yet.

Those who seek to conduct the senior care business in China are well advised to remember a few important rules of the China elder care experience: first, China senior living is where Western geriatric care was in 1950 but gathering steam quickly; second, never judge a project out of context, meaning: comparing a project in Chongqing to a project in Santa Barbara is meaningless as the buyers of the Chongqing project don’t have that choice much less that perspective; third, the higher one stays in the acuity chain, the more leverage one has…which translates into success; and finally, stay in the 1^st class coach, period.

Before this train departs, I would like to make one last observation. My thoughts below are a mildly critical analysis bordering on subjective evaluation and at times, some literary lampooning. Lest I be detained by the People’s Senior Living Police at Beijing Nan Zhan (FYI: an enormous train station), I beg merciful consideration that these contemplations be seen not as cruel condemnation, malicious denigration, negative commentary or, heaven forbid, Confucian blasphemy of any CCRC discussed here or China’s senior living potential in general. Quite the contrary, I am no apostate; I see a bright future and if these three communities are indications of what the Chinese can accomplish right out of the box, then the next decade will be outstanding for professionals in the China geriatric care business.

And finally, as the whistle blows, for those readers not entirely familiar with a CCRC, they are usually defined as a campus style residential complex assembling a mix of independent living residences for active but senior adults, assisted living units for older adults needing some support with their daily activities and skilled nursing care for frail or infirm adults requiring frequent assistance or acute medical care. Additionally, there are often a variety of cultural amenities, exercise facilities and commercial support services which offer basic necessities and provisions, such as hair salon, laundry/dry cleaners and variety store.

A penultimate note:  I have assembled a picture diary of these CCRC’s. If you want to see them you will have to go to my Linkedin page and download the file from Box.net. Find it here: https://www.box.net/shared/06b81943e081479f3ab4

First stop, General’s Garden…..General’s Garden!

When I first visited General’s Garden nearly two years ago, I thought, “This is it….modern senior living has indeed arrived in China”.  But after my fourth trip and some pretty rigorous investigation and analysis, I began to see the cracks in both hardware and software, in a sense, the General’s Garden’s locomotive was running out of steam.

General’s Garden was opened to the public around 2009. It is located in the northeast quadrant of Beijing (off 4^th ring road), not far from Beijing Capital International airport and the Museum of Film. The land was Ministry of Transport land and the property’s perimeter remains a testing track for China’s high-speed railway (true). I refer to General’s Garden as a CCRC as it loosely embodies a simple definition of a CCRC, as outlined above.  Indeed, General’s Garden offers   51 villas or large townhouse style residences with private gardens, 160 independent/assisted living apartments and 280 skilled nursing units all within a gated compound. This facility also offers a 3-hole golf course (plus driving range), an unusual, man-made forested park, an unfeasibly large and as of yet unfinished 17,000m² hot-spring clubhouse, an 160 room inn for visitors and a clinic specializing in traditional Chinese medicine.

So what happened? Well, as of January 2012, only 14 of the Villas had sold and less than 10 residents purchased golf course memberships (which by the way, through October of last year, boasted an expensive, resident Australian PGA Pro to give lessons to all those resident members) since the opening 2 years ago. I would get into detail about the amenity membership program but it is way too complicated (ex. Golf course membership is priced on ball usage). The villas ranging in size from 700-800 square meters, carry a price tag of between RMB 45 million and RMB 55 million for unfinished space and the IL/AL units go for RMB 1.5 million plus services on an as needed, menu basis. And while the IL/AL living apartments and the skilled nursing units are fairly well occupied (75%-80%), there are likely a number of reasons for the stalled performance of the villas. As an aside, I have to note that the best thing about General’s Garden is the aged-care program; it was set up by an Australian group and they did a superlative job. Until recently, an Australian also continued to manage this section of the facility; he has a great deal of experience and insight into how Chinese seniors need/want geriatric care. Kudos to this master of the China senior care experience! Our access to General’s Garden’s business plan has allowed us to tabulate much of their rental and sales data which we share with clients.

Unlike the Little Engine That Could, (“I think I can, I think I can…”) the General’s Garden villas have never made it up the hill. I believe this is because: 1) the land on which the facility is built is known as “collective land” which does not convey fee title to the buyer, only a long term lease (approximately 50 years for either a villa or an IL/AL unit). Consequently, potential purchasers are faced with an unappealing opportunity to buy an enormously expensive, depreciating asset which under Chinese law cannot be hypothecated, 2) General’s Garden never seemed to have a comprehensive marketing plan and buyer outreach program other than pursuing the ownership’s network of political contacts for unit sales, and 3) perhaps the least understood aspect of the facility, its capitalization and financial game-plan which seemed, at best, ad-hoc. Beginning early last fall the warning signals were as subtle as a diesel engine’s piercing whistle at 4am: contractors stopped receiving payments and construction stopped on the remaining units and clubhouse, there was a sharp increase in deferred maintenance, a hostile takeover occurred and subsequently, most senior management ceased receiving paychecks.

On the other hand the IL/AL units are comparatively speaking a success. And while ownership, meaning title conveyed, of such a unit is no different than that with a villa, they are much less expensive (in fact they are well priced at an average of RMB12,000m²). It is interesting to note that there has been a trend of older adults buying these units for their children to live in…..however odd. Despite its raison d’etre as a CCRC, no writ of Chinese law prevents young people from living there. I guess this is an indication of the facility’s pricing as much as its attractiveness, or more likely, the parents intend to move in at some future date.

In late January 2012, new management at General’s Garden, reeling from the enormity of their poorly analyzed, hostile acquisition, fired 12 persons many of whom were experienced senior managers. The terminal analysis is likely that General’s Garden neglected to fully understand their market, didn’t identify a target buyer and never adequately projected unit absorption against capital requirements to identify a breakeven point; a lethal mistake.

I will say though, in all fairness, this review of General’s Garden must contain praise for the original management whose fundamental concept of this CCRC is a sound, well integrated facility; it is just the execution and some software that jumped the track. I have met the previous General Manager and those in his inner circle and believe he/they are talented people capable of positively impacting the senior living industry in China. His early efforts at the facility are proof of this and had it not been for the hostile take-over, General’s Garden would continue to benefit from his leadership and likely turn the train around. However, without him General’s Garden lacks vision and perspective; it faces a number of critical switches in the track ahead.

A fellow blogger recently wrote a piece on this facility using a favorite song of mine to illuminate the bridge over troubled waters that General’s Garden presently crosses and more importantly, its choppy history. I find his story on target and I salute his perspective; he has taken a measured approach to this facility’s analysis. De-accelerating and moving forward less hurried is always a good thing in China.

At this point, I will step away from rock ‘n roll metaphors and, given the time of year, select a more solemn reference as a testament to this facility’s narrative. With its fall from grace, perhaps we can call General’s Garden and its story, “The Prodigal CCRC”, a parable of squandered opportunity; now lost, can and better yet will, General’s Garden atone for its marketing and financial sins and find its way again?

Yanda….next stop……Yanda!

Now this is a facility to behold. While its full name is a mouthful, Yanda Golden Age Health Nursing Center, the facility is frequently referred to as Yanda. One arrives at Yanda entering under an enormous, ceremonial gate and into a Tiananmen Square-like plaza large enough to park 500 tractor trailers. After parking your car, walking around Yanda is, frankly, a little creepy and reminds me of the cities created in the narcotic-induced dreams of Dom Cobb in Christopher Nolan’s Inception, …….beautiful, large, vacant and crumbling.

Yanda’s first impediment is its location, situated a hard hour’s drive from Chaoyang district, Beijing in adjacent Hebei province, it is tough to get too. Second, Yanda simply is overbuilt. So much of what has transpired at this facility is unclear, even the basic facts such as room count and beds are, in typical Chinese fashion, opaque. We are told there are 1,200 units at Yanda, but it feels like more. There is a 3,000 bed hospital and a 200 bed geriatric nursing facility which, management professes is quite busy but there aren’t a lot of cars in the parking lot and not a single ambulance arrived during my 3 hour tour (I arrived at lunch time). But hey, I won’t let my lying eyes fool me, I saw not a single patient in the nursing care center. Wait…there is more: a 250+ room hotel and four places of worship (seriously): Buddhist, Muslim, Christian and Jesuit/Catholic all sited next to a bank (presumably for those whose faith favors Mammon). And if that isn’t enough, ownership built a 30 story building that serves as living quarters for the healthcare workers who will, hopefully, arrive someday soon. Whew! What a budget!

Truly statuesque, in the lifeless sense of the word, this project should be renamed the “Colossus of Hebei” as colossal is the only term that adequately defines Yanda (well, maybe “stalled” has relevance here as well but lacks a certain visual “onomatopoeia”). Now, when confronted with the enigmatic and incomprehensible my imagination always runs wild. In fact, Yanda inspired in me a rewrite of those last few dreadful lines from the famous Shelley poem Ozymandias:

“….My name is Yanda, King of CCRC’s: Look on my campus, ye mighty, and despair! Few residents remain. Round the decay of that colossal wreck, budget-less and bare, the congested Chinese conurbation stretches far away”.

In all seriousness, here is the punch line: Yanda is only 20 percent occupied and it could well be less. I take this fact on face value from what we are told by the tour guide. But having been there at lunch, my favorite time to visit a facility as it reveals a lot, there certainly wasn’t too much activity.

This is what we do know about Yanda: unlike General’s Garden, Yanda is a pure rental scheme. Most occupants lease units on a year basis, but management also quotes 2 and 3 year options. Independent and assisted living units (1 and 2 bedrooms) rent for RMB 5,600 to RMB 9,600 per month plus services which can be selected from a menu. The nursing facility offers beds/units beginning at RMB 13,600 to RMB 16,800 per month, also depending on size and acuity. There is also another quirk to the pricing; the sponsor offers a kind of sinking fund whereby if you deposit sufficient monies with them, they will pay a 6% return on your money that is equal to your monthly rent (the number of takers for this generous offer is unknown). The young lady who showed me and my staff around, gave us the above ‘rack rate” pricing (and a sheet with greater detail on it) but was eager to mention that we are very lucky customers and our visit today was auspicious; management has instructed her to offer high status individuals, such as ourselves, a one-time only, VIP discount of 40% on a full year lease for IL/AL units and a whopping 60% discount for nursing units. Days later, subsequent phones calls to verify information were met with the same offer. Ok…..no surprise here.

Yanda opened up in 2010 and blew its steam before getting out of the station. The ROI has to be hurting by now and somebody is likely to take a loss going forward. It isn’t an ugly project, in fact I found the basic design “ok” by China CCRC standards; but somebody has to take control of the marketing here, drive absorption aggressively and simplify the rental scheme before the buildings fall apart resolving the problem forever. This is the only prospect here: try and compete on price and program in an attempt to overcome Yanda’s real weakness: location. Believe it or not, there is land allocated for a phase II….someday.

Cherish Yearn, last stop…….everybody off!

This facility’s operations are as curious as its name. Located in a distant corner of Pudong, on a former duck farm, Cherish Yearn came to market about five years ago. It was an early arrival to the China senior living space and its organization, facility design and ambience all reflect its vintage. I first visited Cherish Yearn in late 2010 and quite honestly, I thought it was a disaster. From the desert like landscaping to the mold-stained stucco on the buildings it had little ambience, few residents and zero energy.

Cherish Yearn was completed in 2006 and the first residents occupied in 2007. For years it struggled with occupancy and when I returned for a second visit in early 2012, I was pleasantly surprised. Apparently, over the past two years, a new marketing program was implemented and brought census up from a low of 20% to what is reported now as nearly 80%; and after my tour I believe the true figure is not far from this level. Activity rooms are busy with geriatric calligraphers, libraries are full of bespectacled Mandarins gazing over the Central Committee daily and even the computer rooms are full of elderly Chinese pecking away on keyboards. Indeed there is so much activity at Cherish Yearn its resurrection earns it a new name: the “Lazarus of Pudong”…so there is indeed hope for The Prodigal CCRC and the Colossus of Hebei.

Like its sister facilities, Cherish Yearn is large. It offers nearly 800+ units in 15 different mid-rise buildings. Independent living accounts for at least 600 units and there is a 300 bed nursing facility. The independent units have a reported 80% occupancy but it is entirely unclear how many residents are in the nursing facility. Access to the upper floors is prohibited but the first floor, which does indeed have patient rooms, reveals no activity whatsoever and is largely dark.

Cherish Yearn’s business model is founded on a membership scheme with an upfront fee and annual rental payments plus usage charges for the clubhouse and other amenities such as the dining hall. There are 2 basic plans: Plan A essentially confers title to the occupant for an entry fee of RMB 890,000. Once admitted, the resident may choose from 3 basic size units: large units (108m² or 1150ft²), medium units (70m² or 740ft²) and small units (58m² or 625ft²) each of which charges an annual fee according to size. A resident who has purchased a unit under Plan A may sell the unit himself at some future date or offer to the sponsor who will re-purchase it for 90% of the entry fee or market price, whichever is less. Plan B confers a 15 year right of use for an entry fee beginning at RMB 880,000 for a large unit, the smaller units have lower entry fees; there is also a static annual fee of RMB 29,800 across all unit types. Plan B’s entry fee is refundable on a straight declining basis (calculated monthly) over the 15 year lease period.

Plan A seems to be most popular with children who wish to purchase a unit for their parents and Plan B seems to be the choice for elderly who buy for themselves. There are substantially more Plan B buyers than those who avail themselves of Plan A. We have completed a full tabular analysis of Cherish Yearn’s fee structure which, again, is available to clients.

It is fair to mention that in the past, Cherish Yearn experienced some controversy over both its fundamental ability to offer sub-acute care services as well as its adherence to the original land grant use rights. The issues here may have been cleared up but there has been at least one published article in the media discussing the facility’s “land rights” issue the details of which was supported by a credible, well connected source who has since spoken to me directly. In some quiet corners, rumors persist regarding the facility’s legality, but in the end, I can see how this may just be envious chatter over Cherish Yearn’s unprecedented success. Let’s not forget, the truth in China has many layers.

So, in submissive genuflection, I offer faithful congratulations to the Lazarus of Pudong. Despite all, I believe it to be the most successful CCRC project today in China and its program is unique: truly a Chinese sui generis model.

The Terminus

Shanghai Lilly’s assertion regarding the time and effort it took to secure her reputation whistles true and sharp about many endeavors in China; virtues such as patience and fortitude are essential. Likewise, it will take more than just a few attempts at CCRC development to perfect the model in China. CCRC’s are complex undertakings and even in the West, developers with all their access to data and experience often misstep and build mistakes. So it is no surprise that the Chinese incarnation of a CCRC is a wobbly work in waiting. While I see near term success for the smaller, sub-acute facilities currently being built along the east coast of China by both foreign experts and local developers, nothing will dissuade, much less disabuse, the Chinese entrepreneur from pulling the heavy freight of a senior living mega-project. These immense CCRC’s may be the track the industry ultimately takes, but for now were I an investor or owner/operator; my concentration would remain focused on the light at the end of a tunnel:   more manageable, higher acuity and, say, narrow-gauge projects; let’s call them the “Shanghai geriatric express”.

In closing, I have taken this blog’s theme, meaning Chinese films or films with a China theme, quite far…in fact I have extended it further than I ever thought. And this posting was indeed the longest of all postings to date; I did pile it on you, the reader, with endless literary metaphor on top of a mildly amusing allegory, and for this I have not a single pang of guilt. And while I often wonder about Jiang and her whereabouts, I needed to get back to the mechanics of senior living in China; thus the nuts and bolts of this post. No worries, we will revisit the human side of this business again soon and some! I have two more postings of this ilk remaining which I will publish before the summer. After a break, I will return in September with something new and refreshing, but if you have an idea or are curious about an aspect of this business; as always, I am only too happy to listen. Find me here via comment or contact me on bhc@hamptonhoerter.com.

为 人 民 服 务!

Don’t forget: 2^nd annual Retirement Living China conference – Shanghai May 28. This conference is bound to be a real success this year. For more information go to: www.imapac.com.

同 志 好! What follows below is a slightly edited transcript of an interview with a young woman named “Jiang” (alias) which occurred in Beijing, Chaoyang District at a Starbucks coffee shop on December 1, 2011. All edits are primarily due to issues of translation, my imperfect “on the run” typing effort and a very uncomfortable seat at Starbucks. Otherwise, her responses are reported below in as true a form as possible. The purpose of the interview is to shed light on the single most critical issue within the burgeoning geriatric care industry in China: namely, the absolute dearth of properly trained human resources and consequently the use of inadequately trained personnel to administer care to the elderly Chinese. A read through the interview illuminates other social concerns, and while I am sympathetic to these, my focus here is senior care.

Jiang is a young lady of 36 years who is a migrant healthcare worker in Beijing. She is perfectly average for her social cohort in nearly every respect: neither pretty nor ugly, simply dressed, with serious tooth decay and a limited world view. She is a contract employee at a state run nursing facility and has no professional education in nursing other than what she has learned over the past few years. Jiang, and many of the people with whom she works are known as “Bao Mu”, or migrant workers. Being Bao Mu carries a stigma and it is not a pleasant one; they are viewed as wholly inferior, as a lower caste, dirty and unworthy. In reality, I found in Jiang a bucolic charm and a meek honesty which set her in sharp contradiction to her current urban existence; indeed, her life in Beijing could not be more uncomfortably foreign.

As we moved through the discussion, Jiang became more relaxed and began to open up. I did not intend to enter the realm of her private life but as the interview progressed, it became obvious that her past has had profound influence on her current situation. Some of her answers are startling and painful; they paint a vivid picture of not only her job but of her life as well. Lastly, you will notice that the conversation is occasionally peppered with anecdotal comments, either before or after a question, in << >> brackets. I added these notes after a final proof read as I found a simple rote reproduction of the interview resulted in a hollowness which failed to convey the emotional environment.

Jiang arrived at Starbucks prior to the translator and me. She was sitting at a small table in the back of the room waiting patiently with her coat and gloves on, giving a guarded impression and that she considered us a potential no-show. As we approached the table she stood, smiled and said hello. After a brief introduction by the translator and some explanation, I began the interview:

***

Bromme柯博明: Hello, Jiang

Jiang: Hello Sir

Bromme柯博明: My name is 柯博明 and I have a business here in China. I help Chinese businesses build private nursing homes and senior living facilities. I have explained to you that I want to ask you a number of questions about the work you do, how you came to do it, what you think about it and generally about what you want to do in the future. Is this ok? You understand?

Jiang: Yes Sir

Bromme柯博明: Also, I am asking you these questions because I intend to publish your answers in a blog I write. You will remain anonymous, but your responses will be reproduced, after translation and small edits, in their entirety. This is ok for you?

Jiang: Yes Sir

<<Jiang nods in approval>>

Bromme柯博明: Ok, let’s get started. Where were you born and where did you grow up?

Jiang:  I was born in Bishan; I grew up there too; my entire life.

<<Bishan is a rural town near Chongqing. Jiang, obedient and dutiful, asks if she can take her coat off.>>

Bromme柯博明: How old are you?

Jiang: 36

Bromme柯博明: How many years of education do you have? And what have you studied?

Jiang: I studied the basic curriculum

<<This means that Jiang spent about nine years in school>>

 Bromme柯博明: Jiang, I understand that you work in a nursing home, how long have you worked there?

Jiang: About three years

Bromme柯博明: What do you like most about it?

Jiang: The money, but I do not get paid much.

Bromme柯博明: How much are you paid?

<<Jiang was not eager to discuss her salary and I think she found this a little intrusive. There was some conversation between them about my question between the time I asked it and her final response. It was awkward for her and, I sensed a little painful. But I believe she was truthful.>>

Jiang: They pay me 1,500 rmb per month. I also get a bed and some food.

<<This equates to roughly USD235 plus the food and bed.>>

Bromme柯博明: What do you like least about it?

Jiang: I do not like taking care of old people; I am a young person. The old people yell at me and sometimes try and hit me when I have to touch them.

Bromme柯博明: Do you get hit a lot? Why do you have to touch them? What do you mean?

Jiang: Sometimes I get hit but often they miss me because they are slow. The nurses tell me I have to clean them when they shit in the bed. Or sometimes I have to help them go to the bathroom by inserting my finger into their anus. Also, sometimes the families blame us when the old people die.

<<Jiang tried to release this bit of information as if she were sorting laundry, but she could not contain the anguish; it was embarrassing for her.>>

Bromme柯博明:  Does anyone else hit you? Have the nurses ever hit you? The boss?

Jiang: No. My father used to hit me but not the nurses.

<<Obviously, this was unexpected and the result of a miscue in translation. It made both the translator and me a little uncomfortable, and I decided to ignore it for the time being. After a breath, I continued.>>

Bromme柯博明: How did you find your job here at the nursing home?

Jiang: My friends told me.

Bromme柯博明: How did they find this job?

Jiang: I don’t know

Bromme柯博明: What did you do before you worked at the nursing home?

Jiang: I was a food worker. I prepared food in a factory.

<<Her answers here were robotic and truly conveyed that she was disconnected to her job; it was merely a means to an end.>>

Bromme柯博明: Jiang, when you left the factory (Where was the factory?) and came here to Beijing to work at the nursing home, what training did they give you?

Jiang: I worked in Wenzhou. When I was contracted, the nurses told me what to do and after a few weeks I was able to do most of the work alone.

<<Wenzhou is located on the coast of China, not far south of Shanghai. Wenzhou is the crucible of Chinese entrepreneurship.>>

Bromme柯博明: Other than clean the patients, what else are your duties?

Jiang: I feed them, give them medicine, help wash them, help them exercise if they want.

Bromme柯博明: Jiang, how long do you think you will work at the nursing home? Do you have other plans? What would you like to do with your life after the nursing home?

<<This question was either puzzling to Jiang or the translation was off. It took a few iterations to get it on target>>

Jiang: I have to work here because I need the money. Someday I might find another job but I don’t know. I would like not to work here, but I don’t know where to go. I would like to have a shop and sell things.

Bromme柯博明: What type of things would you like to sell?

Jiang: All sorts of things, cute little knickknacks, dolls, sweets!

<<Jiang turned into a little girl describing this. She was almost excited and literally disappeared into another world for a moment.>>

Bromme柯博明: So, Jiang, if I understand you correctly, you work at the nursing home for no other reason than you need the money? Right? You essentially hate the job, nothing about it interests you. In fact, caring for the old people disgusts you…they even hit you sometimes, right?

Jiang: Yes Sir

Bromme柯博明: Do you think you are good at your job? Are you proud to be a health care worker?

Jiang: Today I know my job and I do it, but I do not like it. I am not proud of being a health care worker.

<<The idea of being proud of her job was novel, but once she understood the question, she responded with little hesitation>>

Bromme柯博明: Do you think being a health care worker is an important job?

Jiang: It is not an important job, if it were I would be paid more money.

<<Jiang’s logic was unassailable and her honesty was simple. I was beginning to sense that this idea of mine, that is to interview a migrant health care worker, needed something more. So I decided on a different track>>

Bromme柯博明: I want to ask you some questions not related to your job at the nursing home, ok?

Jiang: Yes

Bromme柯博明: Did you have a happy childhood and are your parents still alive?

<<I felt this was a reasonable subject to explore given her prior admission about her father.>>

Jiang: We are a very poor family. And when I was little my parents had to split up and work in different cities. I had to go and live with my relatives for a long time. One day my father came to get me and take me home. But he would beat me all day and tell me to call my mother and beg her to come home. I had a very bad relationship with my father. My parents are still alive.

<<Jiang opened up here in a way that I doubt she has in quite some time. She was almost eager to say these things. Her answer above is an abridged version of her entire response.>>

Bromme柯博明: If you could buy anything what would it be?

Jiang: A nice house for my mother and a shop for me!

<<Jiang smiled broadly. She missed her mother enormously>>

Bromme柯博明: Jiang, I have only a few more questions. When your mother is old and frail will you take care of her? Or would you consider a nursing home for her?

Jiang: Yes, I will care for her.

<<Jiang oozed empathy>>

Bromme柯博明: But you will have to work, right? How will you take care of her and work at the same time?

Jiang: I don’t know.

<<And again, Jiang’s honesty was never more apparent than in this answer. She paused for a while before answering, looked down at the floor hopelessly and responded without looking up. I think that this may have been the first time she ever considered the difficult situation of either caring for the mother she loves more than anything or supporting herself. I don’t want to read too much into her answer but I suspect that she began to rethink her plight at this moment. Her answer in a way almost made me feel guilty about presenting her with this dilemma>>

Bromme柯博明: Jiang, do you have any questions for me?

Jiang: Sir, why do you want to work in nursing homes?

<<Clever girl, I thought>>

Bromme柯博明: I don’t really work in them. I help people build them and operate them.

<<Jiang waited for the translation. It didn’t appear that my response really answered her question.>>

Bromme柯博明: Thank you, Jiang. I have enjoyed speaking with you.

Jiang: Yes Sir, Did I do a good job?

Bromme柯博明: Yes, Jiang. You did a great job.

<<Jiang rose from the table and put her jacket back on. She thanked the translator, smiled and began to walk out, when I asked her one last question>>

Bromme柯博明: Jiang, have you ever seen the Chinese movie Farewell my concubine?

Jiang: Oh, no Sir, movies are too expensive. Goodbye

Bromme柯博明: Goodbye, Jiang.

***

In my two hours with her, I found Jiang to be much like Chen Dieyi in the film Farewell my concubine.  Not on a superficial level, but in terms of how tortured she must be; caught in the middle of a miserable triangle with the angles of her life defined by a father who beat her as a child, the necessity of holding down a job she despises and a mother to whom she is fully devoted and loves dearly but cannot live with for financial reasons. Making this mosaic more complex, Jiang now knows that she, like millions of other poor and middle income Chinese, face a dreadful dilemma of ultimately having to care for their parents and lose a job or keep the job and turn their parents over to a nursing home.

Update: Last week I found myself in the vicinity of the nursing home where Jiang works. I stopped by to say hello and thank her again for her time. The manager of the facility seemed frustrated when I inquired about her; he told me she had quit her job three days ago and did not know where she went.

She just left he explained, raising his hands in exasperation, “Like all the Bao Mu, appear from nowhere and disappear into nowhere”.

I turned and walked out of the nursing home, leaving behind the caustic tang of bleach and sour reek of dirty clothes. The cold air bit into my nose and cleared my lungs as I stepped outside. I walked down the street and thought about what the manager said regarding Bao Mu disappearing into nowhere. As I hailed a cab, I looked back at the nursing home and pictured Jiang, an apparition with suitcase in hand, furtively leaving her job and escaping under the cover of a foggy dawn into a thoroughly uncertain future.

Full of ephemeral sympathy for Jiang, I thought to myself as I got into the cab, “Indeed, has there ever been a more poignant, unknown destination?”

为 人 民 服 务!

China Senior Living is pleased to announce its sister blog

India Senior Living!

The first blog should be posted in early 2012!!

Find it on www.indiaseniorliving.com

]]> http://chinaseniorliving.com/2011/12/19/farewell-my-migrant-healthcare-worker/feed/ 8 chinaseniorliving http://chinaseniorliving.com/2011/11/27/maos-last-nursing-home/ http://chinaseniorliving.com/2011/11/27/maos-last-nursing-home/#comments Sat, 26 Nov 2011 19:58:01 +0000 Bromme Hampton Cole 柯 博 明 http://chinaseniorliving.com/?p=113 ]]> 毛 时 代 最 后 的 敬 老 院

“The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of communism is the equal sharing of miseries”. Churchill

同 志 好! There is a nursing home in Wuxi called Liang Xiao (name changed). It is located down a side alley off a busy street not far from the central train station. Like most acute care facilities in China, it is a grey and depressing place with little apparent security and wholly inadequate patient supervision. I don’t know when Liang Xiao was built and the distressed nature of the buildings offer little clue; most public facilities (with the notable exception of important government offices) are poorly constructed, it could just as easily be 10 years old as it could be 30 years old. In all, Liang Xiao seems as hopeless and miserable a place as are its despondent and forlorn patients; fragility seems the least of their ailments as patient quality of life is non-existent. To be fair though, Liang Xiao did have an uncommon amount of activity and the type of motion that suggests design; but it wasn’t clear at the time just what it was all about.

I was invited to visit Liang Xiao as a result of one of their nurses having read information my firm, Hampton Hoerter, was posting onto Weibo, the Chinese Twitter. We arranged our visit and scheduled the trip for an early afternoon arrival. Our hosts were the doctors and nurses who run the facility and we were told, the “Chairman” of the company. This last bit of information was curious as I was under the impression that all nursing homes were owned by the state. The purpose of our invitation was to learn if there was any opportunity for us to consult and assist Liang Xiao with their interest in upgrading their geriatric care program.

Shortly after our arrival and once done with the ceremonial exchange of business cards, fanfare of good wishes, obligatory sip of tea and taste of fruit, we were offered a tour of Liang Xiao which we graciously accepted and were told that Mr. Chang would be slightly delayed. Twenty minutes into our tour the Chairman arrived with an entourage of 6 men attending to his calls, carrying his 3 briefcases and just generally making a scene about his arrival. Clearly, the intended impression to be conveyed by this activity was that Mr. Chang was exceedingly important and a much too busy person with whom to be trifled. Our tour guide noticed Mr. Chang’s entrance and nervously diverted us from our route to the courtyard in the center of Liang Xiao where a brief introduction was to be made and photos taken. Mr. Chang was given our brochure by one of his assistants and as he read it out loud, he shook each of our hands. Once the introduction was complete, Mr Chang insisted that our tour be postponed until later that afternoon and we should all, at once, retire to the luncheon which had been especially prepared for us.

Our lunch cleared up the mystery of the “Chairman” as well as Liang Xiao’s noticeable bustle and opened a door into what might well be the future of nursing homes in China. Calling Mr. Chang a businessman is a profound understatement, as he is more aptly described as one of China’s new generation of ravenous entrepreneurs, a new breed of savvy and sharp-eyed capitalists who can spot opportunity a mile away.  Mr. Chang’s story begins a couple of years ago when the 12^th 5 year plan was being written and the government began to allocate funds for the development of senior living facilities. Through what I can only imagine is a carefully constructed and meticulously maintained, salubrious network of political and business contacts (the guangxi must be legendary!) in Wuxi, Mr. Chang crafted himself an opportunity from the ruins of Liang Xiao. And while Mr. Chang doesn’t know a thing about nursing care or even the management of such a facility, we must always remember the 4^th philosophy of the Joy Longevity Club….General Tsao’s copycat chicken with tasty sauce.

Through grants available via the Ministry of Civil Affairs and more importantly, private investment, Mr. Chang is slowly turning Liang Xiao around, and even though it may not look like that today, having been to many other nursing homes in China over the past two years, Mr. Chang is clearly on the power curve of his industry. What is even more curious is that Mr. Chang has also “purchased” shares in Liang Xiao and through his private company “owns” a substantial minority stake. I use the quotations for effect here as I have no idea the inner machinations of how he managed this or the details of the structure; like many things in China the means justify the end and it is likely all informally arranged between him and his local government friends. These particulars notwithstanding, it is the big picture that is the point here: Mr. Chang is moving an industry that has long been mired in the stone age of China’s dismal legacy of anemic public healthcare. Mr. Chang and those who come after him in Wuxi (not to mention the 39,545 other public nursing homes in China) will no doubt profit handsomely from their efforts and they should; theirs is truly a herculean task.

This all reminds me in a way of Li Cunxin’s gripping autobiography Mao’s Last Dancer (and subsequent film adaptation by Bruce Beresford in 2009). In his book, Li Cunxin is born into a poor family commune in a small rural village in Shandong Province, where he is destined to work in the fields as a laborer.  At first overlooked but eventually selected after suggestion by his teacher during a school visit, Li seems bewildered by the gruff preliminary inspection screening at the province capitol city of Qingdao. He is selected to travel to Beijing to audition for a place in Madame Mao’s Dance Academy, and is admitted to its ballet school after passing a series of physical examinations. Years of arduous training follow, until his initial mediocre performance is finally overcome due to inspiration from a teacher’s devotion to classical ballet as opposed to the politically motivated, strident form favored by Madame Mao. His determination and courage leads to him being grudgingly permitted by the Academy to travel abroad to Ben Stevenson’s Houston Ballet company as a visiting student for three months. In the United States, he begins to question the Chinese Communist Party dictates upon which he has been raised, detaches himself from his political past, defects and flourishes as a dancer.

I see Mr. Chang as China’s healthcare Li Cunxin; a charismatic, determined soul who sees more and desires a better circumstance for himself and his business and is frustrated with the status quo. The big difference between Li Cunxin and Mr. Chang is that Mr. Chang no longer has to defect to realize his ambition; China has learned to provide opportunities for those who are motivated enough.

A short injection of China’s nursing home history

In 2000, China’s Ministry of Civil Affairs announced the “Star Light (Xing Guang) Program” whereby the Ministry allocated 20% of the social welfare lottery fund to build community welfare facilities for seniors. From 2001 to 2004, the Chinese government invested a total of 13.4 billion yuan in this program and built 32,000 “Star Light Centers for Seniors.” The services of these centers are overly broad with multiple functions and cover family visits, emergency aid, day care, health care services, and recreational activities to over 30 million elders. At the same time, the government also increased its investment in building nursing homes to provide institutional care for older people in the “Star Light Program”. Another program, the “Beloved Care Engineering” program began in 2005 and is aimed at increasing the number of nursing homes and encouraging good nursing home care quality through a government-sponsored Elder Care Foundation. These facilities range from senior citizens’ lodging houses (apartments), older people homes, and nursing homes for the aged, which serve to meet elders with different functional abilities and financial backgrounds. The building of older people homes in rural areas was also encouraged for persons who can avail themselves of the “5 guarantees” which, when translated, are the basic needs of “food,” “clothing,” “accommodation,” “health care,” and “burial service”.  Those who can usually find their way into such accommodations are usually former revolutionary guards, government employees or other “proud” occupation. By the end of 2005, there were 39,546 institutions providing vastly different types of services for seniors with most providing subpar care, when compared with their Western counterparts (an admittedly unfair comparison). In total these institutions provided 1.497 million beds.

If providing nursing homes was the only issue then China would be well on her way, however that is the least of concerns.  As with most endeavors on the mainland, human resources or lack thereof is usually the issue that trumps the best laid plans. The major source of healthcare workers are (often called “bao mu” in Chinese) laid-off workers in previously state-run factories, migrant workers from rural villages or unemployed ethnic minorities. They often do not have any training in elder care or nursing home care before they start working in the nursing homes for older adults. For laid-off workers, 1 to 2 days of short training in basic personal care is provided free of charge by some local government agencies, for example the Labor, Social Security Bureau, China Committee on Aging, and Women’s Federation. However, none of these workers are required to have formal training in geriatric care before they enter into their work. As a result, the quality of care is grim and dangerously low. These workers are often required to pay a fee for these training courses and as this imposes a great financial difficulty, they usually do not enroll before they commence working. Such labor also presents other issues for working in nursing homes; different language or dialect, customs from those of urban cities’ older people and cultural prejudices of patients who often dislike their care being given by “bao mu”.

We haven’t yet begun our work with Mr. Chang, although I am confident we will do a great deal with him. And as you can imagine, the benefits of working with such a person extend far beyond simple contract remuneration. His highly choreographed performance to date in raising Liang Xiao from little more than a living graveyard to real, albeit spartan, nursing home is nothing short of virtuosic.

为 人 民 服 务!

Note: Portions of this posting, in particular the history of nursing homes, were drawn from “Nursing Homes in China” by Leung-Wing Chu, FRCP, and Iris Chi, MSW, DSW 2008

Consider attending the China Investment Summit USA conference in New York, Nov 30-Dec 2. BH Cole delivers a presentation on the power curve of the China senior living industry.

See https://www.box.net/s/bbvufy7rmqp9df3u5gt3

The Practical Challenges of Cultural Translation

同 志 好! Throughout Amy Tan’s The Joy Luck Club, the various female narrators meditate on their inability to translate concepts and sentiments from one culture to another. The incomplete cultural understanding of the mothers and the daughters is a result of their incomplete knowledge of language. Indeed, the barriers that exist between the mothers and the daughters are often due to their inability to communicate with one another. Although the daughters know some Chinese words and the mothers speak some English, communication often becomes a matter of translation, of words whose intended meaning compared with their accepted meaning are in fact quite separate, leading to subtle misunderstandings with big consequences.

I could transcribe the above paragraph nearly word for word and have it apply to a western company’s experience in bringing their business to China, especially geriatric healthcare. This experience for many has been frustrating and this is almost entirely due to both party’s inability to understand that the translation being provided for them at the banquet table is imperfect. Each party departs that table with a partial comprehension of the conversation that transpired. Like the mothers and daughters in The Joy Luck Club, it is also fair to say that the misunderstanding  between an American businessman and his Chinese counterpart is not relegated to the superficial; in fact they approach their meetings assuming they are very different and neither of them realizes that they have more in common than not. Consider for a moment that these two have richly mixed identities rather than identities of warring opposites.

Said another way, the differences between American culture and Chinese culture can be summed up as follows:

Consider China a high-context culture (by context, I mean the whole situation, background, or environment connected to an event, a situation, or an individual) in which the individuals have internalized meaning and information, so that little is explicitly stated in written or spoken messages. In conversation, the listener knows what is meant; because the speaker and listener share the same knowledge and assumptions, the listener can piece together the speaker’s meaning. China is a high-context culture.

In contrast, a low-context culture is one in which information and meanings are explicitly stated in the message or communication. Individuals in a low-context culture expect explanations when statements or situations are unclear, as they often are. Information and meaning are not internalized by the individual but are derived from context, e.g., from the situation or an event; America is a low-context culture. At some point because we are all human, low context culture communication meets high context culture communication; this stratum is not a bright line but a seam that is broad and contains meaning and perspective to both cultures.

When American businessmen fear that the American and Chinese cultures cannot mix and therefore doing business in China is perilous, they are contemplating the combination of two extremes of the high/low context dynamic. In reality, each identity is itself mixed: just as the American culture is not wholly about autonomy, liberty and individuality, the Chinese culture is not wholly about passivity, obedience, and self-restraint. Nonetheless, the challenge of finding a way to combine aspects of both into a successful venture is a challenge faced not only by the American businessman in China but the Chinese businessman in America.

Membership in The Joy Longevity Club

There are four fundamental principles of working in China which I have found to be essential to beginning to understand the Chinese. This last phrase, “understanding the Chinese” is the catch here and it leads me to the frustrating and slightly contradictory statement that one must understand the Chinese culture before you can understand the Chinese. It is a rich, complex culture with boundless mysteries all of which have been developed over the past 5,000 years. So, understanding the Chinese and their approach to business is a puzzle. Nevertheless, these four principles, which I call the “Four philosophies of The Joy Longevity Club”, regard situations and people which you will inevitably come in contact with; they will help you and, tongue in cheek, are below:

1)     The man with a hundred wives: He’s a clever chap, this one, squeezes Yuan from stones. He’s got a piece of every action imaginable; the taxi driver’s fare he hailed to take you to the hotel, the lunch he “paid” for, and if money changes hands within his sight, he has a cut. He is not dishonest; he is the pinnacle of an entrepreneur, the ultimate broker and China is full of them. Knowing him as such is a first step in understanding him and using his considerable network for your gain.

2)      False-positive affirmation of non-confirmation: Here’s simple axiom for doing business in China, learn it, internalize it and life will be much simpler for you: Yes means maybe, yes can also mean no and yes might indeed mean yes but no invariably means no…..got it? Don’t be frustrated, just practice and master this sly bit of linguistic subterfuge and you are half way there….maybe.

3)      Same-same but different: This is a disarmingly innocent but crafty little riddle that really only serves a person to advance a particular situation at another’s expense. All I can say is “At what point in time are two dissimilar objects identical?” Answer: When the salesperson is desperate for a sale. But be especially concerned when the attorney you’ve hired to represent your interests says the same thing to you about a matter of Chinese law. Usually the use of this phrase means that your powers of critical thinking are paying off….the questions you are asking are exasperating him…..keep it up.

4)      General Copycat’s spicy chicken with tasty sauce: This is the main meal that has nourished the Chinese economic miracle. Usually the first generation of copied product is a blatant failure while the second is an improvement and works but is still commercially unacceptable. The third generation however is an inferior product but marketable and the fourth is nearly indistinguishable from its foreign counterparts in nearly every respect except for one: it is much less expensive. This last point, the cost of the product being substantially less, is the point of liminality when the Chinese “gotcha”.

I was recently at a Chinese banquet, the guest of a successful man who owns a large company and was looking to get involved with senior housing; I’m interested in selling him some business. Here is how the conversation went:

Me: Attempting to demonstrate proficiency with chopsticks, I remark in high context language, “Mr Chang your interest in senior housing is quite timely and I like your project’s location.”

Mr. Chang: Displaying supreme ability with chopsticks as he draws his spicy chicken nearer, he says “Xie-Xie. We have diligently been preparing for our opening.”

Me: …..”Opening?” The slippery chicken I had managed to pinch with my chopsticks drops back onto my plate, splattering my shirt with spicy sauce. “I was under the impression you were interested in receiving our proposal for strategic operations assistance?”…I stammer, in full retreat with low context language.

Mr. Chang: Never taking his eyes off his plate, he devours his chicken, gnawing voraciously on the bone. He responds with false-positive affirmation of non-confirmation, “Yes!”

Me:  Batting away the subterfuge, I penetrate, “How can we help you Mr. Chang?”

Mr Chang: Smiling broadly and gesturing to the waiter that he is finished with his chicken, he says,  “We return from our USA trip where we visit two senior facilities. We took a lot of pictures! We would love to read your proposal.”

Me:  Mr. Chang’s hundred wives are useless against me now! I counter with a masterful same-same but different tactic, “Ah, this is a clever move Mr. Chang and I am sure you learned a great deal. What you learned on your trip will be of great use…..” I pause to release the obligatory burp that demonstrates my deep satisfaction with the taste of the chicken…exhaling, I continue,”…especially…. your newly found knowledge of geriatric nutrition and memory care”.

Mr. Chang: On his heels and defensive, using false positive affirmation of non-confirmation, he responds, “Yes.”

Me: At this point I must enable Mr. Chang face, I reply in high context language, “Your knowledge of this industry will make you an icon of China senior living! I only hope to offer you support in this voyage, Mr. Chang.”

As it turns out, Mr. Chang not only thought he could build a skilled nursing facility using pictures but he had plans to establish a hospital as well….also from the pictures they took on their recent visit to the US. After an initial attempt at replicating a facility from pictures, Mr. Chang quickly became a client. Fortunately for the geriatric healthcare consulting business and Western geriatric care companies, the fourth generation of SNF/ALF and liminal profitability for the Chinese is 10 years away.

Now, a serious word about the future

With all joking aside, explosive economic growth has been one of the major driving forces behind almost every industrial sector in China; and the healthcare industry is no exception. The country represents one of the most rapidly growing major healthcare markets in the world with total healthcare spending having produced compounded growth of nearly 23% over the past four years making China the fifth largest healthcare market in the world. And with its current momentum, many expect China to surpass Japan by 2013 to become the second largest healthcare market in the world.  If that isn’t enough, China’s healthcare expenditure accounted for a microscopic 4.6% of its GDP in 2009, well below the global average of 10%.  By way of further comparison, its East Asia and Pacific neighbors spend 6.3% of their GDP in healthcare; so the potential growth is obvious.

China’s increasing affluence has brought upon it a frightening rate of urbanization. Accompanying this urbanization are natural lifestyle changes such as western diets, modernized transportation, and intensified work schedules; all of which have shifted disease patterns from communicable to chronic.  These shifts increase demand for recurring healthcare treatment.

The higher acuity of care a geriatric services company offers is proportional to their longevity and profitability in China; whereas the extent to which one reduces specialized services, the more you diminish your advantage.

Western geriatric care companies interested in China would be well advised to heed the following: the Chinese demographic that is most attractive and, frankly, the most natural play for Western healthcare IP is, at present, the high end of the market that will avail itself of assisted/skilled nursing care facilities and other specialty services such as dementia care. And while I believe there is opportunity for Western companies to get involved with independent senior living in China, this market has much more competition. The more you reduce specialized services, the more you diminish your advantage.  So while the economic story is compelling the real difficulty in China is execution and mastering the low context culture vs. high context culture dynamic; for Western geriatric care companies, membership in The Joy Longevity Club is exclusive and takes time.

为 人 民 服 务!

Note: Certain material in this post was drawn from Cowen and Co. Hong Kong and Lilia Melani of Brooklyn CUNY.

“远 程 监 控 医 疗 护 理”  蕴 藏 无 限 商 机

同 志 好! There is no shortage of metaphor in Chinese culture. From language to art, it is a highly philosophical society and one that loves acknowledging, often in extravagant ways, its traditional values; the Chinese are also quick to turn and embrace the latest technological innovations with a coy wink and a nod.  This seemingly mild contradiction between reverence of the past and infatuation with a cutting edge lifestyle is a mystery of sorts. But why not? The Chinese love ambiguity and are not troubled in the least by incongruity.

In Ang Lee’s blockbuster Wuxia epic, Crouching Tiger, Hidden Dragon, there are many poignant moments on which to drift away in endless contemplation of China’s mysteries.  Yet one moment stands out in particular: The chief protagonist of the film, Mu Bai, knows that clinging to his personal affection for Shu Lien is contrary to his Wudan way of detachment; yet in Shu’s company he finds something that has eluded him in his meditations. In their second key exchange, during the film’s midpoint, Mu Bai goes so far as to take Shu Lien’s hand and press it to his cheek; yet even here he is held back by the implications of his philosophy. A moment later, in an uncharacteristically romantic moment that underscores Mu Bai’s Xia code of ethics, he peers into Shu Lien’s eyes and says,

“Shu Lien, the things we touch have no permanence….there is nothing we can hold onto in this world. Only by letting go can we truly possess what is real.”

Ah…..here we have it all, enigmatic, impenetrable…and perhaps inconsistent but always attractive and enticing.

In a way, and maybe a tad stretched, I find Mu Bai, his words and his actions relevant, almost allegorical to China’s healthcare evolution and in particular its epic, Wuxia-like journey to self-actualize geriatric medicine. Like Mu Bai, who struggles to reconcile his affection for Shu Lien with his Wudan discipline, the story of China’s senior health care evolution is cryptic and captivating at the same time; always searching for an elusive goal but restrained by a reluctance to let go of the past only to possess, as Mu Bai lectures, what is real. This pursuit of the abstract for some durable conclusion or permanent truth and the attainment of such, at the price of one’s culture, is what I call a “Mu Bai reality”.

Today, across China, developers are waking up to the opportunities for senior living and they are not dissimilar to entrepreneurs everywhere; aggressive and acting to fill a demand.  Many of these developers are experienced builders, but most of them do not possess the skill set necessary to offer the elderly tenants the care and service expected….much less initially promised. Further, when few if any industry wide regulations exist to standardize a product, the results can be “consumer unfriendly”, meaning seniors are moving into communities without any care regimes and no near term prospect for such. And since there is no established geriatric care practice in China, consumers don’t really know what they don’t have.

As I said in my first post on this blog, Enter the ageing Dragon, this practice is changing, as western senior care providers begin to enter the market and as China herself, learns the science and the art of elder care. China’s healthcare evolution in this sense is highly transitional and lacks permanence. As its senior care industry pupates within a chrysalis comprised of western geriatric competence, modern technologies and traditional Chinese medicine, it undergoes a profound metamorphosis; a transformation that requires it to release a portion of its cultural history in order to evolve. The question is: into what does it evolve? When China senior care industry “lets go”, as Mu Bai implores Shu Lien, what will it possess?

The “Mu Bai reality” of China’s Healthcare

When I think about the size of the population in China that (today) requires some sort of specialized geriatric attention and likely goes without, I am reminded of the Law of Large Numbers. If I were to envision a perfect world where every senior citizen in China could avail themselves of a senior living opportunity if they needed it, whether it be nursing, independent or assisted living, I would be dreaming of over 350,000 facilities. This is, to say the least, fiscally impractical and likely impossible even for a “China-sized” budget. So, I wonder, “What is the solution?” Well, the Law of Large Numbers (a theorem dictating that results obtained from a large number of trials should be close to the average of a single trial) tells me that the expected solution for all is not far from the average solution for delivering senior care to 165 million Chinese elderly.

The average solution and the answer, I believe, enabling geriatric care (to non-terminal, ambulant persons) to cover 95% of  China’s ageing population will be one that utilizes information and communication technology (ICT) to monitor, diagnose,  evaluate and maintain patients. ICT is simply a combination of information and communications technologies and is used as a general term for all kinds of technology which enable users to create, access and manipulate information. China is an increasingly interconnected country, the interactions among devices, systems and people are growing geometrically. Businesses need to meet the demands of their employees and customers to allow for greater access to systems and information: ICT enables all of these communications needs to be delivered in a unified, scalable way. This unified platform reduces costs and boosts productivity across a business and beyond. ICT has merged into most every aspect of daily life in China from commerce to leisure and even culture; witness the ubiquity of mobile phones, desktop computers and hand held devices. In most respects, save political, ICT is making China a global society, where people can interact and communicate swiftly and efficiently. There is no more mystery here, in an abstract sense, ICT has become part of China’s technology “Mu Bai reality” in the 1980’s when it “let go” of parts of its past.

The healthcare expression of ICT is Telemedicine. It is a relatively simple concept whereby a doctor can remotely assess the health of a person using devices which measure numerous criteria such as blood pressure, glucose level, temperature, weight and others.  These devices already exist, and some manufacturers are producing “all-in-one” portable combinations that sit on top of a table facilitating ease of use. After the device performs its user administered measurements, the data is transferred (wirelessly or via internet connection) to a central assessment unit for interpretation and comparison with personal historical data. If necessary, the doctor can contact the patient via VoIP and if sufficient broadband is available, live video discussion can ensue for greater evaluation. It is estimated that a doctor can “visit” and assess hundreds of patients a day via Telemedicine, dramatically reducing costs by restricting real office visits or home visits to those patients who truly require in-person evaluation. To my mind there are 5 compelling reasons (taken from Johnathan D. Linkous, CEO of ATA) why this technology works:

1. Telemedicine can increase effectiveness and efficiency in
geriatric medicine.

 2. Currently available technology is sufficient.

 3. Remote central assessment units can be
located within a hospital or other existing clinic.

 4. Technology transforms seniors from patients to consumers.

 5.  It offers greater quality of life for seniors by maintaining personal independence and the continuity of living at home.

But just because Telemedicine “works” or that ICT is a viable application to healthcare, why will it work in China? The answer is because the vast majority of older Chinese are not rich, will never be rich or live in remote areas and thus unable to afford a specialized, live-in, dedicated facility or to travel to a doctor on a frequent basis. Not even under some contemplated, distant reality of a Chinese social security or pension system will most of these people have such an arrangement. So, the least expensive, most practical solution which offers the best care to the most people will be implemented. Thus, I conclude using the Law of Large numbers that Telemedicine is the “average solution” and the way most Chinese seniors will receive geriatric care. Even those seniors living in China’s new assisted living facilities could avail themselves of this technology and facility operators increase their revenue while decreasing their fixed costs.

There is another reason to expect this outcome. China, over the past 30 years has taken large leaps and bypassed certain technology waypoints in their route to further modernization and “Mu Bai realities”.  Witness, the land line telephone: the West used land line telephones for 40 years before cellular technology was developed. But because of China’s emergence onto the global scene relatively late last century there was no need for widespread use of land line telephone technology. Essentially, China went immediately to cellular communication and skipped a whole generation of technology. Cellular was less expensive, more effective and easier to implement across a vast geographic region. Telemedicine should be no different. This example is just further support for the thesis of this blog that Telemedicine is the future not just of healthcare in China, but geriatric medicine especially.

Telemedicine is a disruptive technology in the same way that the car disrupted and reodered transportation last century. Horses, ultimately became entertainment and owned dominately by the rich.  One can only speculate today on telemedicine’s full impact on the future of healthcare, but it will certainly alter it in ways that are, initially, uncomfortable for many.

Once China internalizes the fiscal constraints of traditional, “Westernized” senior care for its burgeoning elderly population, discharges the obsession with historical geriatric care programs, it will “let go” and achieve the “Mu Bai reality” of Telemedicine.  This technology will enable modern, geriartric care for tens of millions of Chinese seniors in far flung locations, inexpensively and in a way that retains their independence. None of this is to say that Western geriatric care competencies are not highly appropriate to a China application. In fact they are, and significant export opportunity exists here for Western practitioners in so long as these skills are “trans-culturated” and delivered in a Chinese context; in doing so an ironic twist of circumstances might occur and the West may also achieve the “Mu Bai reality” of Telemedicine. A hidden opportunity lurks within Telemedicine and it is poised to leap like some striped feral beast!

As a final amusing and certainly less serious thought, I can envision an appropriate sequel to Crouching Tiger, Hidden Dragon which might contain further dialogue between Mu Bai and Shu Lien, now in their 80’s and elderly themselves, as follows:

Mu Bai, now pre-diabetic, has just completed his blood pressure analysis and his glucose test. He presses the green send button to transfer his data to the central assessment unit. He looks up at Shu Lien, who having just finished her own self-assessment with their State provided Telemedicine monitor, is preparing for a session of morning Tai Chi with co-stars Jen, Lo and Sir Te.

Mu Bai sits back in his chair and says to Shu Lien: “Shu Lien, although I am no longer as agile as I was so many years ago, but I would like to go back to Wudan Mountain for further meditation….come with me Shu!”

Shu Lien, also still young at heart but often forgetful replies: “Mu, please leave these things to the young warriors. We have mahjong after lunch and….I don’t remember….but our afternoon is busy!”

Mu Bai insists: “Dutiful wife! My Telemedicine device is portable! We are going!” Mu Bai begins to stand quickly but his ageing knees force him back to his seat.

Shu, coming to help Mu Bai stand, reassures him: “Dear husband, let us be grateful for our independent lifestyle and accept this new, harmonious living for aged persons……..Mu Bai, it has a permanence that is indeed real.”

Camera fades to nearby Wudan Mountain.

If you have not seen this movie, I highly recommend it for an insight into Chinese culture.

REMINDER: Retirement Communities World begins on October 10 and runs through October 12. The conference takes place this year in Hong Kong and it promises to be a grand show! Please consider registering – www.terrapinn.com.

同 志 好! This is China Senior Living’s inaugural blog. Here, you will read about my opinions on the state of the industry, new events, conferences, project updates and other relevant matters. At first, my entries will be posted randomly and time goes on I will attempt a more consistent and frequent blog.  I also intend on having industry icons as “guest” bloggers as well. But first things first…

This is China Senior Living !

As a general statement, senior living today in China is a trend and a trend that is consigned exclusively to the upper end of the market. In all fairness however, it is a trend with extraordinary facts that underpin its potential; all of which evidence and corroborate a likely near term transformation into a full-fledged industry. These realities are:

1) Demographics: China’s well known and highly publicized demographics indisputably show that it is facing a dramatic transition from a young to an aged society in the coming 10 to 20 years. In 2000, there were 88,110,000 persons aged 65 years and older, which represented 7% of the population. Today this figure is closer to 150 million or 13% of the total population; and by 2020 those over 65 will total an astonishing 265 million. There are no official statistics that account for the relative wealth of those in this age cohort, but it is  safe to say that the overwhelming majority of those over the age of 65 are rural poor. Less than 10% could be considered middle class (western standard) and a corresponding 1% deemed wealthy.

2) 4-2-1: Because of the peculiar 4–2–1 family structure in China, one can expect that older Chinese adults will increase their use of senior living facilities in the coming years. With the China’s burgeoning economy, the lure of prosperity and the consumerism that follows, it is unrealistic to expect that the remaining one child will remain at home to care for the elders. Additionally, the Chinese government has realized that a) it is financially  unsustainable to expand in this area using public resources and b) they have no real understanding of gerontology as witnessed by the government’s “Star Light Program” and the “Beloved Care Engineering” launched in 2001 with suboptimal aged care services to say the least. The government’s current policy, outlined in both the 12^th 5 year plan and the recent Circular 58 legislation is to encourage private and foreign investors to participate in the retirement housing business in China.

3) Filial Piety: The Chinese tradition of caregiving for older family members is and has always been an inward looking phenomenon; they rely on family members to support all aspects of an elder’s care. This is what the Chinese refer to as the value of “filial piety.” In fact, China’s constitution mentions that “…Children have a duty to support and assist their parents…”.  While most of the younger persons in China still maintain the attitude that taking care of the older family members is their responsibility, more and more of China’s youth are unable to provide all of the family support functions and require some outside assistance. This is due in part to the 4-2-1 phenomenon mentioned above as well as the impact of China’s prosperity and the consequential trend of small nuclear and empty-nest families.

Yet these facts which will transport the trend into an industry are constrained by a single, stark reality; there is no geriatric health care operator currently in practice in China with the knowledge base that is required to adequately care for a frail, elderly population. This is not to say that there are no such facilities, indeed there are and at last count, I have found and visited about 25. However these facilities are real estate plays and/or strictly independent living opportunities with little or no care services (to wit: Golden Years in Hangzhou). Alternatively, there are facilities that have attempted aged care services but the reality of caring for a frail census far exceeds the ability of the hired staff whose training is simple nursing. The point here is something I have tweeted about previously and is an axiom of the senior living business in China:

The tipping point that transforms China senior living from a trend into an industry is the development of “localized” operators who have assimilated and culturally integrated the fundamentals of aged care into an acceptable Chinese context; simply translating western operating manuals into Mandarin is doomed to fail.

Alas, I think it was Confucius who once said that necessity is the mother of invention and indeed there is at least one geriatric care operator in formation at present and should be open by late next year. This nascent operator will open his doors in a flagship prototype specifically designed for long term aged care. It will be a small facility, which not doubt puzzles the Chinese given their propensity for Freudian accomplishments, but going forward the operator plans to offer contracted services only…..A brilliant move. I need to also mention another facility that is truly a model of Chinese senior care (near) perfection. General’s Garden in Beijing is a CCRC that is at least 5 years ahead of anything else in China built to date. This is not to say that there aren’t issues or mistakes as there are, but from a design and service POV, GG takes the CSL Blog Award for outstanding facility!

All the above is to fully suggest that there is enormous opportunity for western senior living companies. However, the opportunity must be approached with humility, patience and a willingness to fully adapt your care programs to a Chinese sensibility and temperament: this is elemental, essential and of liminal importance.

In my next blog, I am going to address the existing facilities in more detail; their pricing structures, business models as well as how I see western operators being successful in China. Subsequent to this, I plan on discussing the watershed Circular 58 ruling in greater detail as well as a primer to the legal vehicles one might use to enter and exit China in the senior living business.

Thanks. I hope to hear from as many of you as possible.

NOTE: Retirement Communities World conference is in Hong Kong this year. It is being held on October 10-12. I urge all who are interested to register at Terrapinn’s website. www.terrapinn.com