Five years ago, I carried out a survey of rural families in which at least one member had been diagnosed with a mental illness. My survey site was a remote mountain village located in the southwestern province of Yunnan. Although I’d braced myself for the worst before arriving, I was nonetheless distressed by the appalling living conditions of many patients.

Hundreds of miles from the nearest psychiatric hospital, villagers were wholly reliant on a single village doctor who had little mental health training. Although he made regular house calls, if patients’ conditions worsened, all he could do was advise their families to bring them to the distant psychiatric hospital for treatment and medication. Community treatment for mental health problems was unheard of.

In retrospect, the situation in that mountain village could have been worse; at least I didn’t encounter any cases of patients being chained up inside their homes by family members.

Working in mental health in China, especially in the countryside, can feel like a hopeless endeavor. As a middle-income country, China’s health and medical resources remain limited, especially in the field of mental health. In China, there are fewer than three psychiatrists per 100,000 people; the OECD average is more than 15. China’s social work and psychotherapy professions lag even further behind the developed world. According to a 2019 paper, there are just 1,000 rehabilitation psychiatrists, 1,500 mental health social workers, and 3,000 psychotherapists working in professional institutions across China — a country of 1.4 billion. Mental health accounted for less than 2% of total health care spending in 2020.

What mental health resources do exist are concentrated in large cities along the coast like Shanghai, while mental healthcare in the countryside and the country’s poorer western regions is extremely scarce. A 2015 study found that 41% of counties in China did not have a single institution providing mental health services. In practice, this means that hundreds of millions of Chinese, many of them in rural areas, do not have access to the help they need. Although progress is being made — over the past few decades, mental health workers have done much to improve the lives of mentally ill people in rural areas, including providing them with basic treatment and financial aid — rural areas still lag far behind cities.

At present, the responsibility for caring for those with mental illnesses is shared between families, communities, and institutions, with families bearing the brunt of the burden. Numerous studies from around the world have found that the majority of people with mental illnesses live with family members. In China, this manifests as the social obligation for families to take care of members who are unwell.

This obligation puts a huge amount of pressure on families, especially in poorer communities. Once that pressure exceeds the family’s ability to cope, problems are likely to arise; for example, patients are sometimes left in the hospital or locked in their homes.

Education and support services for families is vital. Yet these are scarce even in urban China, to say nothing of the countryside. In rural areas, the lower socioeconomic status and levels of education of family caregivers mean many are unfamiliar with mental illness, do not know how to provide proper care, and sometimes harbor deep-seated prejudices and misunderstandings regarding mental illness. As such, they may end up choosing the simplest and crudest method for dealing with family members with mental illnesses: locking them up.

It is important to note that such methods are rare. For the vast majority of families, their situation is one of helplessness, as they try to care for their loved ones as best they can under impossible circumstances. In my clinical practice, I have encountered family members who have little sympathy for patients, but far more often I find myself comforting families through their tears and pain. I always try to ask myself: how much support and help has society provided these people? If our society has failed these families, how can it blame them for failing to take care of patients?

One way to relieve the burdens on families is to increase community-based services. Over the past two decades, China has made continued efforts to promote community-based mental healthcare, especially for those with severe mental illnesses. However, in rural areas, the implementation and effectiveness of these measures remains uneven.

This is in part because of widespread prejudices toward those suffering from mental illness, to which even policymakers and clinicians are not immune. Since mental health is widely seen as unimportant, improving mental health services is not a priority in many places. Some local policymakers and doctors even believe that mental illnesses are not treatable, and as a result, patients just need to be prevented from causing trouble rather than protected or cared for. When these ideas are allowed to take root in policymaking and healthcare circles, institutional discrimination against those with mental illnesses is the natural result.

Meanwhile, village doctors remain the main providers of community healthcare for people with mental illnesses in rural areas. Many of these doctors are already burdened with heavy administrative workloads and poor pay. Those village doctors who emphasize mental health can make a positive difference, but in many cases local care amounts to little more than filling in forms. It’s clear from practice that village doctors cannot be the sole source of community care for people with mental illnesses in rural areas.

Institutions, the step above community-based care, are not in much better shape. Most of rural China lacks institutions equipped to provide mental health services, and even areas with access to institutional support and medical services struggle to affect change at the community level. Studies have found that medication alone does not significantly reduce the use of chains to restrain those with mental illnesses, for example – other community support is also needed.

That said, there are proven community support methods for people with mental illnesses that are suitable for rural areas. For example, sustainable livelihood projects run by organizations like BasicNeeds have had success helping people with mental illnesses reintegrate into society by providing vocational and technical training. But these kinds of programs remain rare in China.

There is a risk, when discussing the problems facing rural health care, that we fall into a self-defeating rhetorical circle. Sometimes I’ll hear arguments to the effect of, given the limited resources, we can’t ask for too much. If we overburden them, we’ll just make matters worse. When I hear cynical arguments like these, I wonder: Does this mean people in these areas deserve second-rate mental health care?

Views such as these are reminiscent of the international debate many years ago around the treatment of patients with multidrug-resistant tuberculosis (MDR-TB) in low- and middle-income countries. Decades ago, most of the global health community felt that MDR-TB treatment was too expensive and not cost-effective. This created a vicious cycle, as governments invested little in treatment, and patients were left to suffer on their own.

But the issue at stake wasn’t financial, but ethical. We take thehigh cost of treatment for granted, but do we ever stop and think about who is driving up the price of drugs? What about the global capital chain benefitting from these expensive treatments?

Proponents of expanded treatment for tuberculosis, such as the recently deceased Paul Farmer, a professor at Harvard Medical School, and Jim Yong Kim, a former president of the World Bank, insisted that patients in poorer countries shouldn’t be denied treatment because of their own lack of resources. Through advocacy and negotiations, they drove down the price of treatment drugs and ultimately improved access.

The Chinese countryside is not wealthy, and if you assume that mental health treatment must be cost-effective, nothing is likely to change. But if we insist — on an ethical basis — that people with mental illness in the countryside have the same right to care as those lucky enough to live in major cities, we can break the vicious cycle in which underdevelopment is used as a pretext for underinvestment.

The village I visited in Yunnan was not the worst-case scenario I used to think it was. But as I listened to patients’ stories of discrimination and how they were, willingly or otherwise, confined to their homes, I thought this cannot be the best we can do. It’s important to break the physical shackles locking people with mental illness up. But breaking the invisible chains — the stigma of mental illness, the unequal distribution of mental health resources between cities and the countryside, and the poor quality of mental health care in rural areas — is no less vital.

Translator: David Ball; editors: Cai Yiwen and Kilian O’Donnell.

(Header image: Visual elements from Muhammad Rinandar Taysa/EyeEm and ekazansk/iStock/VCG, reedited by Sixth Tone)