Opening Minds in China

As soon as he leaves the hospital, Qu Yi says confidently, he and his fiancee can finally get married.

His “Little Swallow” has already come to Guangzhou from her hometown to plan their wedding, he says. During the day, she slips into his locked and barred ward, then vanishes into thin air afterward. At night, while he watches TV, Qu confides, she sends him secret messages over the airwaves that only he can decipher.

To Qu, it’s love. To his doctors, it’s a delusion, born of a mind rent by severe schizophrenia. Neither Qu’s fiancee nor his upcoming wedding really exists.

Qu is one of more than 1,300 schizophrenics at China’s oldest psychiatric facility, here in the heart of Guangzhou. They are part of the growing number of people now recognized as mentally ill in a country that once dismissed them as victims of bad karma or as political misfits whose problems stemmed from improper Communist ideology.

Millions of Chinese every year are diagnosed with afflictions ranging from minor depression to major psychosis. Psychiatric drugs such as Prozac are widely used, replacing “treatments” that once consisted of studying Mao’s quotations.

But far more of the sick don’t receive the care they need. China, with one-fifth of the world’s population, also suffers from one of the highest suicide rates on Earth. Ignorance, high medical costs and the heavy stigma attached to mental disease discourage people from seeking help.

Those who do are confronted with a tottering public health system that is ill-equipped to serve their needs--and that experts predict will be even less able to meet the swelling demand for psychiatric services in the future. Virtually no one in the countryside gets free care anymore, and free health care for urban workers is declining rapidly as state-owned enterprises go under.

“It’s going to get worse before it gets better,” warned Michael R. Phillips, a Canadian psychiatrist in Beijing who has studied mental health care in China for the past 15 years.

The magnitude of the looming crisis in mental health is difficult to pin down, because the topic remains politically sensitive with the Communist regime, which fears that a high count of mentally ill people somehow reflects badly on its rule.

Officially, just 16 million people suffer from psychiatric disorders out of a population of 1.2 billion. But both Chinese and Western experts scoff at the government figure, saying the real number is easily twice or even three times that.

A recent report by the World Health Organization estimated that more than 60 million people in China were afflicted with some type of mental disease in 1990. Depression alone affected 16 million residents at any given point during the year and schizophrenia more than 4 million, the study said.

While scholars debate the exact figures, no one doubts that only a fraction of the sick receive proper treatment in a land with just 110,000 psychiatric hospital beds and an even more serious dearth of physicians and psychologists trained to handle mental illness--a paltry corps of about 13,000.

By contrast, the U.S. boasts twice as many hospital beds and nearly 200,000 psychiatrists and psychologists who serve a population about a quarter the size of China’s.

“To have 11,000 to 14,000 psychiatrists, depending on how you count it, [for 1.2 billion people], you’re kidding yourself,” Phillips said.

Many victims follow the path of Qu, whose family balked at the idea of mental disease and waited 3 1/2 years before bringing him in for treatment at the hospital in Guangzhou.

By then, Qu’s condition had grown progressively worse and his delusions increasingly elaborate. He would sneak out of the house in the dead of night for trysts with his nonexistent girlfriend. He chased neighbors out of their home, insisting that the house was his to live in after his marriage.

Qu, 28, is now on medication and lives with the other patients in his ward, men like Professor Zeng, a mild-mannered academic who is convinced that his wife is trying to poison him, and other schizophrenics who have spent months in the hospital.

The men mill about in their thin white pajamas, watching TV, singing karaoke, playing pingpong and fanning themselves to beat the southern summer heat. Women occupy their own wards. Facilities are basic and stark. Sharp objects are stowed out of reach.

The 3 1/2-year delay in seeking treatment will probably mean a longer recovery time for Qu, said his doctor, Jiang Zeyu.

“The key is to detect and treat it early,” Jiang said. “If society better understood these symptoms, people would go to the hospital earlier. But society’s understanding of [mental illness] is extremely shallow.”

The ignorance harks back to ancient tradition and more recent misguided policies by China’s Communist rulers.

Notions of bad karma, divine wrath or possession by evil spirits still color views of psychiatric disorders, especially among the 800 million residents in China’s vast countryside.

“They think that you did something bad, or that your ancestors did something wrong,” said Chen Hsueh-Shih, who at 83 is the doyen of psychiatrists in China. “It’s like Europe in the Middle Ages.”

During the 1950s and ‘60s, fanatical communism took over from superstition. Particularly during the 1966-76 Cultural Revolution, mental illness was considered the outcome of clinging to the wrong ideology. Officials dismissed psychology as a bourgeois Western science.

An editorial in the People’s Daily recommended political re-education as the proper cure for problems of the mind--in contrast to what was happening in the Soviet Union, where political dissidents were being treated as mental patients.

At the Guangzhou Psychiatric Hospital--which had been treating the mentally ill since it was founded by American missionaries in 1898--patients were taken off their regular medication and put on a course of Mao Tse-tung’s quotations and traditional Chinese herbs. Other facilities in the country were shut down altogether.

Psychiatry didn’t reemerge until about 20 years ago, when China opened up again to the outside world, but it remains hobbled by the interruption. Few medical students opt to specialize in psychiatry, which is still looked on as the ugly stepchild of modern medicine. Mental health professionals earn among the lowest salaries of China’s physicians, about $125 a month.

The marginalization of psychiatry means that general doctors themselves are often ignorant of mental disorders and don’t know how to diagnose or treat them, while specialists are sometimes hard to find.

Li Ningzhong counts himself lucky. A mental clinic at his university hospital allowed him to escape a depression so profound he had trouble getting out of bed. In the mornings, he would beg his friends to stay so that he wouldn’t have to be alone. At night, he would clutch his bedposts to keep himself from leaping out of his dormitory room window.

Last December, a physician at the clinic put him on an antidepressant and assigned him light physical work, a course of treatment that Li credits with saving his life.

“When the doctor told me it was an illness and that it could be treated, I was filled with hope,” said Li, 23. “Before, I thought I had no way out.”

Li now recognizes that two of his brothers also suffered from depression, for which they were never treated. One of them, he said, remains withdrawn. He is determined to spread the word about the disease so that others “understand it’s nothing to be ashamed of.”

The stigma associated with mental illness is still so strong that even those who have made a full recovery often face the prospect of losing their jobs, their housing and their spouses. Psychiatric problems are still seen as a source of shame to one’s entire family.

In his efforts to promote awareness and understanding of mental disease, Li has an ally in international pharmaceutical companies, which see China as a huge well of untapped profit, particularly for antidepressants, the fastest-growing segment of the psychiatric drug market.

Sales of Prozac have jumped 50% every year since the drug’s introduction to China in 1995, according to representatives from manufacturer Eli Lilly. Prozac now accounts for 40% of the antidepressant market in China. The drug is even available over the counter in pharmacies around Beijing.

Industry estimates say that the overall market for psychiatric drugs in China has exploded in the past five years, increasing by almost 700% to about $200 million in 1999.

Ironically, the same economic reforms that have enriched drug companies have taken their toll on the state health-care system and made psychiatric care less accessible for many Chinese.

Mental hospitals, forced to compete in the open market, have had to resort to serving customers who can afford to pay high fees while cutting back on treatment for the poor, the increasing ranks of China’s uninsured and the slightly ill.

More and more facilities are closing unprofitable wards--even at Anding Hospital, Beijing’s most famous treatment center. Many psychiatric hospitals in poorer provinces such as Hunan, Sichuan and Jiangxi are only 50% to 80% full and don’t have enough money to pay their staffs.

“This is a tremendous problem for the mental health field,” said Arthur Kleinman, an expert on mental health in China at Harvard University. “It’s very substantially underfunded. And since the Chinese Ministry of Health is already very tightly budgeted, I can’t foresee in the future that there’s going to be an enormous amount of money poured into the mental health field from the [state] sector.”

Kleinman estimates that in China, as in other developing countries, less than 1% of spending on public health goes toward improving mental welfare.

Last November, the Chinese government publicly committed itself to combating mental illness, acknowledging the problem and embarking on studies and awareness programs in conjunction with the World Health Organization. It was an important step forward, experts say, for a regime that first drafted guidelines for protecting mental patients more than 15 years ago but has never got around to approving them.

Popular media have begun publicizing the need for better mental health. Articles on how to spot psychiatric illnesses are now common fare in mainstream newspapers. One of the most-watched TV shows in Beijing last year was “The Psychology Clinic,” a 20-episode series about visitors to a local clinic who suffer from a variety of problems: obsessive-compulsive disorders, phobias, even bizarre fetishes.

But as awareness increases, the strain on China’s health-care system will only worsen as more people seek treatment, unless the Communist regime backs its words with the necessary cash to fund research, train more psychiatrists and make medical care affordable.

It has already cost Qiu Mingjiao about 50,000 yuan ($6,125) to find help for her son from a succession of local doctors--an exorbitant amount of money in a country with a yearly per capita income of $1,000. Both she and her husband are unemployed. The family’s savings are gone; they have had to borrow money from relatives and the bank.

Her son, Zhou Feng, 25, complains of loud voices in his head and recounts imaginary conversations with President Jiang Zemin and the late Deng Xiaoping. At one point, Zhou believed his little brother to be the reincarnation of Mao.

Now Qiu is at a loss as to what to do. There is nothing for her son in their village in Jiangxi province, she says: no psychiatrists, no job, no wife, no future. Other residents look askance at her family and whisper among themselves. “These people won’t say it to my face--just behind our backs,” Qiu said bitterly.

And what began as a problem for her son has turned into despair and possibly depression for her too.

“I worry day and night. When I cook, my hands tremble. If you collected all my tears, they would fill buckets,” Qiu declared, then paused.

“I think about ending it all myself--jumping into the river,” she said, “so I don’t have to see my son suffer anymore.”

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Chu was recently on assignment in Guangzhou.