A Rising Tide Lifts All Boats? A Chinese Paradigm By Herbert S. Sacks, M.D. APA President

In early October I addressed the plenary session of the Regional Meeting of the World Psychiatric Association in Beijing. During the preceding two weeks, I had visited five cities, giving talks and touring university medical centers. In anticipation of the journey I read several books on Chinese history, politics, economics, and personal accounts of Chinese citizens who had survived the Cultural Revolution. I reviewed the sparse cross-cultural psychiatric literature starting with Lee and Kleinman’s article earlier this year in the Harvard Review of Psychiatry. Most importantly I discussed psychiatric and social issues in China with distinguished scholars affiliated with the Yale-In-China Program, human rights advocates and psychiatrists who have visited China in the recent past. Hardly an expert on China and Chinese psychiatry, I was a quick study tutored by the best and the brightest - but without command of Cantonese or Mandarin Chinese. I began a journey to Eastern China that was fascinating, straining credulity, and really hard work much beyond my experience as codirector of a major project in West and Central Africa for over a decade.

The briefest observations on how China views the world will provide context, together with your recollections of President Jiang’s American sojourn a few weeks ago.

In the 13th century China was the most advanced nation in the world, with the largest cities, the greatest shipping and commercial undertakings, the most educated physicians, and the most sophisticated technology. Later, with humiliating foreign imperialism, the disintegration of the Qing Court (1644-1912), the Opium Wars (1839-42), and finally the establishment of the Republic in 1949, famine, political chaos, shame, and years of demoralization deeply affected the lives of the people. For a decade beginning in 1966 the Cultural Revolution, led largely by cadres of young peasant activists, brought about destruction of the country’s cultural treasures, the detention and execution of large numbers of professional and educated people, and the "reeducation" of others by exiling them to work side by side in the fields with the peasantry. Psychiatry and the social sciences were seen as espousing unacceptable Western middle-class values, and mental illness was understood to be a consequence of failed capitalist systems. Chinese professors of psychiatry told me that there was a marked increase in suicide rates during the era of the Cultural Revolution. Not a surprise.

In 1978 Deng Xiaoping’s economic reforms began a revolutionary transformation in this vast nation of 1.2 billion people. Recently the World Bank reported that China grew economically four times in the last 20 years and, with qualifications, predicted that China will grow seven times in the next 20 years. President Jiang Zemin at the 15th Communist Party Congress committed himself to continuing Deng’s policies. While 200 million people have been lifted from poverty, the government bears responsibility for keeping in place a system that at times is cruel, limits village-level democratic experimentation, and pursues the rule of law until it touches upon official party arbitrariness. The explanation for what we cite as human rights abuses is rooted in this huge, almost ungovernable, and heterogenous society. Without controls, the government fears for the consequences of open discourse and the erosion of values. President Jiang in Washington, D.C., stated that China’s most important human right is subsistence and development. "Before adequate food and clothing is insured for the people, the enjoyment of other rights is out of the question."

In America we are committed to individual liberty. Our British friends emphasize legality and order. The Chinese have no history of liberty but have a deep investment in pursuing commerce that will affirm its position as a world power and lift its people to a better living standard. Presidents Bush and Clinton believe that constructive engagement together with a thriving economy will bring to China democratic influences.

The national bird of China is the crane. Fifteen percent of the world’s construction cranes are in Shanghai. New building construction is everywhere, but too many buildings in the Pudong commercial sector of Shanghai are empty. Smog obscures much of the cityscape in every city I visited, with massive contributions of particulate matter from burning bituminous coal. President Jiang’s American trip successfully consummated China’s attempts to buy nuclear reactors for clean energy production.

The popular culture in the coastal regions reflects the West’s colorful clothes, tastes, and music. CNN Shanghai shows clips of beautiful models on walkways wearing couturier fashions, a woman having cosmetic surgery, Karaoke clubs, and medical commentary about the increasing incidence of eating disorders. There is a well-established middle class on the coast and much evidence of a small but growing upper class.

The burgeoning economic growth has its own serious structural problems. Depending upon whom you speak to - Chinese or Americans who live in China - 50 percent to 85 percent of the factories are bankrupt, and most of the banks are insolvent: Their bad debts exceed their capital. Chinese economic survival lies in the direct foreign investment of $175 billion, making China the second largest recipient of international investment, after the United States. Economic problems notwithstanding, American policymakers believe that the phenomenal economic growth in China is a rising tide that will lift the boats of democratic virtues.

In the past decade, China sent 250,000 students to the United States, including young people from the ruling families of President Jiang and Foreign Minister Qian Quichen. The 100,000 students who have returned home bring back more than advanced degrees. They also carry new impressions of an open society, a thriving market economy, the rule of law, due process, government accountability, and the role of minority rights. This infusion of Western ways will ultimately lead to more shared values.

Some returned Chinese students seek changes at the child-rearing level. A Kansas-State Ph.D. in education runs Beijing’s largest private kindergarten, imbued with American views of early childhood development. Rather than following the traditional childhood virtue of being guai, or docile, his 180 pupils paint, roller-skate, and sing in what he calls "creative anarchy." His goal is to create individualism, letting children grow at their own pace according to their own interests and endowment.

In my WPA plenary talk I said, "We are proud that many of your psychiatric scholars have come to our country for collaborative work and study, allowing them to become familiar with the wide scope of psychiatric thinking and treatment modalities. We have much to learn from each other, and I look forward to learning from you in a climate of guanxi."

Guanxi means "personal relations and trust," and once established, there is no length that Chinese will not go to in confirming that familial feeling of loyalty and friendship.

Psychiatry is rooted in individual liberty, seeking independence and autonomy for our patients. In many single-party nation-states in the world, psychiatry has not come under ideological pressure. But there are inevitable tensions between the principles of human dignity, independence and autonomy, and the cultural sovereignty of nations, each with its own rich heritage. Such is the case of China. From the viewpoint of psychiatric theory and practice, there is much opportunity to reduce these tensions on the playing field of science, invoking guanxi.

With this background, look for my second column on China in the next issue of Psychiatric News, December 5. I will write about Chinese medical and postgraduate medical education, single-child families and kinship, the question of educational standards and certification, my visits to two university medical centers, and health care coverage for the people of China.