Social Realities in China Today

To the Editor: I was excited to see the informative and optimistic column on mental health reform in China by Tse and colleagues (1) in the July issue. The authors’ positive description of current developments inspires hope for this vast and influential country. As one might imagine, an increase in community mental health also makes political sense by creating a “harmonious” society, enhancing quality of life for people with mental illnesses, and reducing economic loss to the society. Such reforms have been long overdue.

I have concerns about the general SWOT (strengths, weaknesses, opportunities, and threats) analysis by the authors that tiptoed around the larger societal and policy-level issues. The authors seem rather wishful that community mental health problems will be greatly helped by increasing funding in that sector. However, the reality is that no meaningful, substantial social changes have been undertaken to create a basic safety net for people with serious mental illnesses. China has no unemployment security, the current public medical insurance is woefully not in keeping with the actual costs of medical care, and welfare for the indigent is still a remote idea. In the context of these social realities, individuals with serious mental illnesses are not likely to spend precious time and resources to seek or secure care. Available care is typically targeted to those who have adequate insurance or families who are willing to pay, and there is still enormous pressure for any service to be self-funding and profitable. Making money on the backs of people with serious and chronic mental illness is never achievable. Social reforms in regard to safety-net creation are needed—not simply increased funding that does not address issues of social inequity and barely keeps up with the rate of inflation in China today. Spending that is not guided by reform of the social safety net will miss the point.

My second concern is the unsatisfying assertion that technology and innovations of the “Information Age” can themselves lower stigma. Stigma remains the most significant barrier hindering development of a mental health care system. One could argue that stigma is promoted by the Information Age as much as combated by it. We need more evidence-based, culturally meaningful, and government- and citizen-driven efforts at many levels: legislation, welfare support, disability recognition, and employment equity, to name a few. The Internet by itself is not going to solve this.

I think the world stands to gain from the well-thought-out and implemented experiment in community mental health on which China is currently embarking. China is likely going to borrow and reference some well-known models developed in the West, such as the psychosocial rehabilitation model mentioned by Tse and colleagues. One needs to be aware of the potential fallacy in knowledge translation across cultures. Developing China-specific and culturally meaningful programs is another interesting challenge.