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The dark side of growing old – The Economist – 18.04.24

A coming wave of Alzheimer’s and other forms of dementia will test China to its limits.

Mr ZHANG HAS stared down death during his 90 years on Earth. He has been diagnosed with cancer twice. During his latest bout doctors gave him 18 months to live. “That was 16 years ago,” he recalls wryly. Trim, snowy-haired and energetic—the key is “no exercise” and “no smoking”, he says—the retired manager cuts a dash in a blue shirt, green trousers and black cotton slippers.

Yet on this spring afternoon in the city of Hangzhou, Mr Zhang is afraid. Not of death, but of dementia. In his youth, the old who lost their faculties were called “crazy”. Later the Chinese learned about a disease named by foreigners: Alzheimer’s. He has feared it for years. Advanced sufferers cannot recognise their families and so always feel alone or numb, he sighs: “That is the most terrible thing.” Quietly he adds that he has begun to forget things.

Mr Zhang is luckier than many. He lives in his own apartment with his wife (88). Hangzhou is one of China’s richest cities. His home district of Gongshu is a pioneer, used to test government plans for tackling dementia, a disease on the rise as China ages.

Officials estimate that 53m Chinese have some form of cognitive impairment, of whom 10m have Alzheimer’s. That number will grow as Chinese live longer, for the risk of Alzheimer’s soars after the age of 75. Various dementias already have 16,000 inhabitants of Gongshu in their grip. The district’s residents are older than the national average and enjoy a life expectancy of 83, similar to Japan’s, explains Li Qiuyang, who directs old-age services at the local Centre for Disease Control, a public-health agency.

Mr Li has made early detection of dementia a priority. He invites specialists to hold clinics in neighbourhood health centres and asks university professors to give popular-science talks, working to overcome a pervasive belief that memory loss is just part of ageing.

Chaguan encounters Mr Zhang in a publicly subsidised, privately managed community centre full of features designed to slow cognitive decline. The 90-year-old has dropped in to collect a coupon for a cheap haircut and is not staying long. The same centre offers residential care, charging around 5,000 yuan ($691) a month. On an upper floor, residents with dementia are being helped to make clay-and-paper collages.


A corner is filled with Mao-era items to stir long-dormant memories, from old enamel mugs to a green canvas satchel. The surrounding neighbourhood is a pilot scheme in its own right, with large graphic signs on shop fronts to help those with dementia buy fruit or find the pharmacy.

Public and private hospitals are expanding old-age services, preparing for the time, around mid-century, when China expects to have more than 500m people over 60. The community centre in Gongshu is operated by Lejoy, a private health-care firm. A company executive, Fan Yixin, says that old-age services barely turn a profit for now, in part because today’s elderly have low expectations for their own comfort, after enduring the Cultural Revolution and other disasters. Those born in the 1960s will be more demanding as they age, she says. When they begin to ask for high-quality services “that will really be an opportunity for us.”

For now Gongshu is an exception, not the norm. Few places are as prosperous as Hangzhou, one of 50 pilot cities chosen by the central government to test a range of elder-care programmes. And though lots of countries face challenges as they age, China starts with some disadvantages. Half of adult Chinese men smoke. Chronic conditions including high blood pressure, depression and diabetes are common and poorly managed.

All those are risk factors for dementia. For a country boasting a space programme and aircraft-carriers, China has a weak primary health system. Many community doctors spend three years or less at medical school. As a result, sick city-dwellers crowd into large hospitals to seek care from specialists. Lots of rural patients receive traditional Chinese medicines from poorly trained village doctors.

Insurance coverage is patchy. Cognitive tests for detecting dementia are widely available, but brain-imaging scans—an important tool for confirming Alzheimer’s—are expensive for patients.

This January China became the third country, after America and Japan, to approve lecanemab, a new treatment for Alzheimer’s. But at up to 200,000 yuan ($28,000) a year, it will be unaffordable for most. Dementia is not one of the chronic diseases that public insurance schemes must cover. Chinese families already save at high rates, fearing ruinous health crises. More awareness of dementia will reinforce that behaviour, sapping consumer demand.

A cruel disease that finds society’s weak points

Dementia threatens to widen rural-urban divides. In China families must fund residential elder care themselves. The largest state-run pension scheme, for salaried urban workers, pays retirees 3,600 yuan a month on average. Migrant workers or farmers may receive pensions of just 200 yuan a month, putting nursing homes out of reach. In rural areas, many of these homes are bleak places, reserved for the poor without families to support them.

Typically, urban families rely on grandparents for child care. In villages the old raise left-behind children, while working-age adults toil elsewhere. The age at which Chinese marry and have children is rising, so future grandparents will be older and more prone to dementia. Daughters (and daughters-in-law) will face pressure to quit work or return to villages to care for stricken elders. Young women are already reluctant to have children. It cannot help if a growing number must look after sick parents (often with no siblings to lend a hand, thanks to the one-child policy).

China’s leaders have taken for granted free labour from the old and from adult daughters and daughters-in-law. The state relies on family savings and on local governments of very different means to fund health and social services. That already creates dramatic inequalities. Dementia will test that system to its limits. ■

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The dark side of growing old – The Economist – 18.04.24
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Read more from Chaguan, our columnist on China: What Ramadan is like in Xinjiang (Apr 11th)China’s tin-eared approach to the world (Apr 4th)China’s low-fertility trap (Mar 21st)

Also: How the Chaguan column got its name

This article appeared in the China section of the print edition under the headline "The dark side of growing old"

Photograph: Chloe Cushman

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