Last month, China’s state-run news broadcaster China Central Television aired a program dedicated to the lives of workers at nursing homes and other elder care institutions in Beijing. The show focused on what it called the “three highs” and “three lows” defining the profession. That is, high turnover, high workload, and the high average age of care workers, and their low social status, low salary, and low levels of educational attainment, respectively.

While watching the program, I could not help but recall my own experiences conducting research at nursing homes across China. Despite the country’s growing acceptance of — and reliance on — institutional elder care over the past few decades, elder care workers remain a largely invisible part of Chinese society. Many Chinese elder care professionals are themselves from marginalized backgrounds. In Beijing, the average elder care professional is 54 years old. Mostly middle-aged workers who were laid off from once-secure jobs at state-owned enterprises during the country’s marketization reforms or rural migrants with little in the way of professional training, they are members of a generation used to hardship and difficult working conditions.

In a typical nursing home, the conflict between high workloads and the need for individualized treatment inevitably forces workers to make trade-offs between physical and emotional care. The latter is vital, but cannot be objectively measured or rewarded, and it is often invisible to families, the public, and even the nursing institutions where they work. This means it is at the discretion of each care worker to choose how much emotional labor they will perform in the course of their shifts.

Peering behind this veil of invisibility and unaccountability, however, I found many care workers have turned inward, appealing to a deeply personal moral sensibility to keep themselves motivated and provide effective care for their elderly charges. In particular, care workers draw on ingrained moral sensibilities like a belief in reciprocity to bolster their sense of moral responsibility, mitigate negative social perceptions of their work, and comfort themselves about their own uncertain prospects as they enter old age.

Lin, a 53-year-old elder care worker in the central city of Wuhan, has been in the industry for over five years. Like many of her co-workers, Lin was laid off from a state-owned enterprise — in her case, a formerly state-owned department store. Pushed into the job market with little in the way of skills, she worked sporadically before landing a job in a government-sponsored nursing home. It’s hard work: When I first met her, she was so preoccupied with the elderly residents placed in her care that she barely had time to talk to me. But the real stress isn’t necessarily the workload itself. Lin told me that, because the most visible part of care workers’ jobs involves dealing with the messy consequences of aging, they are often written off as doing “dirty work” no one with other options would choose. “We work from dawn to dusk, and I seldom complain,” she said. “It’s the disrespectful attitude of others that could kill you and make you feel worthless!”

Keenly aware of the negative stigmas attached to their jobs, many care workers seek to morally justify their work by emphasizing their role in upholding the key traditional value of reciprocity. In particular, they invoke the belief that “a good person will be rewarded” — that they are helping pay society’s debt to the older generation, and that their care for vulnerable elders will likewise pay off when they themselves need care in the future.

Xu, Lin’s co-worker, told me that her work helps fulfill the state’s obligation to a generation that made great contributions to China’s rapid development in their youth. In the process, she positively contrasts the profit-driven logic of private care homes with more welfare-oriented state-run nursing institutions like the one where she works. “Many elders would be charged a much higher nursing fee if they went to a private nursing home,” she said. “We do a lot for them for free!”

In Lin’s case, her faith in reciprocity is tied to the belief that her care for others will have a modeling impact on her only son, making him a more moral and filial person. One of the key ways reciprocity manifests in Chinese culture is through the notion that adult children have the obligation to care for their aging parents, just as their parents once cared for them. The country’s marketization of elder care and the subsequent lack of familial involvement, however, have given many Chinese elder care workers a front-row seat to what they perceive as the erosion of this principle.

For her part, Lin believes her faith in reciprocity is paying off. She says her son now voluntarily does housework and has become more understanding of her job. He’s even begun encouraging Lin to visit her own mother, who lives alone in a rural village. While publicly insisting that she will not impose on her only son for elder care, Lin shares stories from her job to keep him “informed” of the unfilial behaviors of other children.

Cultivating a strong sense of morality allows care workers to continue performing their work despite both the stigmas attached to their roles and their lack of social recognition or financial compensation. In recounting her experience with one male elderly resident, I could sense Lin’s pride when she described how she managed to improve his health condition, even after his family had lost hope for his survival. “I often talked to him when I was in his room, though I hardly received any response,” she said. “Some colleagues told me not to waste time on him as we had many other residents to care for. But I wouldn’t want to be left alone if I were him. So I persisted, and he slowly began to speak again!”

Still, it’s worth noting that the reliance of current elder care workers on traditional morality poses problems for the sustainability of China’s elder care workforce as a whole. In particular, as China’s population ages and family dynamics continue to shift, it will face a growing demand for professional care workers. Currently, the ongoing lack of public investment in the elder care profession is being masked by the current generation of care workers’ sense of moral responsibility for their charges. But younger workers are less willing to put up with the low salaries, poor benefits, and social stigma of working in nursing homes. And while the current generation of care workers may be willing to cope with these challenges, they are getting older. Without more support and better working conditions, compassion fatigue may well set in.

In short, China’s elder care system is being held together by unpaid and unrecognized emotional labor on the part of care workers. This group’s moral sensibilities and attachment to traditional values like reciprocity have no doubt benefitted the welfare of elders in their care, but it cannot be the foundation of a sustainable industry. More public investment and recognition of elder care work is vital to ensure China will have a motivated, effective workforce capable of meeting China’s burgeoning elder care challenges. Otherwise, it is unclear where the next generation of care workers will come from.

Editors: Cai Yineng and Kilian O’Donnell; portrait artist: Zhang Zeqin.

(Header image: Elderly people take part in outdoor activities outside a nursing home in Zhengzhou, Henan province, 2019. People Visual)