Psychiatric Times May 2005 Vol. XXII Issue 6
As previously reported (Psychiatric Times November 2004, p1), the World Psychiatric Association (WPA) and the Chinese Society of Psychiatry (CSP) agreed to an extraordinary meeting to discuss clinical, ethical-legal and diagnostic issues arising out of allegations of political misuse of psychiatry involving practitioners of Falun Gong and political dissidents. The meeting took place in Beijing in the last week of February and included presentations by leading Chinese psychiatrists and a delegation of seven WPA experts. My role in the delegation was to provide expertise in law and psychiatry. Working with student assistants, we had done extensive research on the Falun Gong, the reported allegations of abuse and background material asserting that Chinese psychiatrists had adopted Soviet-style tactics of political misuse of psychiatry. What follows is my personal account of the meetings in Beijing and how that experience changed my understanding of these matters. At the outset it is important to acknowledge that despite all of the research, I was ill-prepared for what I found in China.
During the week that the WPA delegation was quartered at the American hotel in Beijing, a free, English-language newspaper, the China News, was slipped under the door each day. One brief item in that newspaper put everything I had learned in a different perspective. The China News of Feb. 25, 2005, told a story about a 60-year-old father, a villager from Jilin Province, who had given his right arm so that his son could stay in college. The father's arm had been caught and mangled in a cotton-processing machine. He had been offered a choice: an expensive operation that would save his arm or a cheap amputation. He chose the amputation because his son needed the money for his college tuition. One might think the Chinese would want to conceal such cruel market economy choices in health care from English-speaking visitors; after all, China was once the land of barefoot doctors and the bastion of communist equality. But the father's choice to give his son "a brighter future" was presented as a heroic act of parental sacrifice in the real-world, free market economy of present-day China. And indeed what we found in China was that psychiatric facilities had been cast adrift by the state and expected to survive or fail in the market economy based on their entrepreneurial ability to generate revenues from their patients. China was far from Soviet-style psychiatry, and the changes had come about not by the enactment of mental health care laws, but as a result of the economic reforms that are transforming every sector of the Chinese landscape.
What this means is that in most cases, patients, their families, their villages or their employers must subsidize psychiatric hospitalization. Most of the rural population (like the sacrificing father) have no health insurance and, for those in the cities who do, there are significant copayments for psychiatric hospitalization. There is no communist equality in health care, and the primary directive in Chinese psychiatry is not about politics--it is about money, and psychiatry in China occupies the lowest rung in the medical hierarchy. With a population of 1.3 billion citizens, China has only 4,000 qualified psychiatrists and a total of 14,000 doctors working in its psychiatric hospitals. The stigma of mental illness remains an overwhelming fact of life in China and this sociocultural reality creates a barrier to care and makes the specialty of psychiatry less attractive to promising young doctors. Given the stigma and the lack of care available, it is not surprising that more than 90% of patients with schizophrenia get their primary care from their families and would be destitute without them. For most of the mentally ill in China, the family is the only support system. And for the psychiatric profession in China, the central concern is how do they make a reasonable income at the bottom of the medical ladder. Given the economic incentives and the greed unleashed by the free market, one of China's greatest problems is corruption, both among officials and the new entrepreneurs. There is every reason to believe that this corruption has infected the health industry, the medical profession and psychiatry. The "dangerous minds" in China are focused on the bottom line, not on ideology or politics.
If I had gone to China with the impression that psychiatrists, and particularly forensic psychiatrists, were power players in a monolithic Chinese communist bureaucracy, I came away with a quite different impression. Psychiatry in China is a struggling profession, with little market power and low income, low prestige, low sociocultural value and little public influence. The consistent response we got from the Chinese psychiatrists we met in Beijing was that their government had no need (and no use) for psychiatrists in dealing with political dissidents.
Chinese forensic psychiatrists have nonetheless been portrayed as playing a critical and malevolent role in their government's persecution of political dissidents. The most damning allegations describe them as engaged in systematic political abuse of dissidents from the time of Mao's regime. This claim was impossible to credit even before this trip to China. Psychiatry has always been a marginalized profession in China, and during the Maoist era psychiatrists were much more likely to be the victims of the Cultural Revolution than its enforcers. Most psychiatric facilities were closed down during the Cultural Revolution, and those that remained open were required to use political reeducation as a primary basis of treatment. Certainly during the years of the Cultural Revolution, all of the secure facilities were taken over and run by political operatives who had little use for psychiatry or psychiatrists. Forensic psychiatry, we were told by Chinese practitioners, did not exist in any meaningful sense until the 1980s.