I cannot mention the real name of the woman who first took me to the orphanage, which is in southern China, in a complex that houses some 300 to 350 children and 250 disabled or elderly adults. I will call her Christine.
The kind of work Christine is doing was one answer to my question about what good, beyond sheer economic prosperity, the Western business presence in China might be bringing to that nation. The question had bothered me during the 1993-1994 debate about whether to renew China's most-favored-nation status. The public discussions had highlighted the gap between Americans who did business in China, most of whom wanted the renewal of MFN status, and human-rights advocates, who by and large supported the Clinton Administration's initial requirement that China first make "significant, overall progress" on issues of human rights. Human-rights advocates were naturally suspicious of business, and the businesspeople's obvious economic interests weakened their argument that their presence in China was good for human rights. I was acquainted with numerous Western businesspeople in China and knew that many had come to love the country. I suspected that some were quietly involved in "good works," serving the cause of human rights while avoiding publicity. My hunch proved correct.
The wives of foreign businessmen and diplomats had formed an association, one foreign businessman and his wife told me over lunch in an elegant joint-venture hotel. They had "adopted" a local orphanage. A small group visited once a week. Most women, particularly those with small children, found visiting the orphanage too painful, but everyone contributed to the children's well-being--toys, clothing, shoes, quilts, screens to keep out the flies and mosquitoes. The couple gave me Christine's number. A resident of China for several years and an active volunteer, Christine was a regular visitor to the orphanage. I called her immediately.
The children who were old enough and able to walk were waiting at the windows when we arrived, broad smiles on their faces. They exclaimed over Christine's oversize bag when we walked in, knowing it would be filled with crackers. Christine had a surprise for them that day--sneakers in bright colors and psychedelic designs, which she distributed to the barefoot children according to approximate size. The children tried them on, jumping and prancing and running, their thumbs up in the universal language of delight. They were an unruly, unsocialized group. Some were handicapped. Others seemed retarded, though the foreign volunteers were convinced that what appeared as retardation was often really a failure to thrive, the result of too little love and attention.
The vast majority of the children, some 90 percent, were thought by the foreign volunteers to be girls, though this was not readily apparent. Their hair was cropped short, institutional-style, and their clothes were unisex shorts and T-shirts. Few of them were actually orphans. They had been abandoned--victims of China's one-child-per-family policy and of the traditional, economically motivated propensity to value males. Males both carry on the family line and provide for their parents in old age. Girls marry and then have obligations only to their husband's family. Rural China has no pension system. The retired depend for survival on their sons.
Recent census figures indicate how badly the Chinese want boys. In 1994 the worldwide sex ratio at birth was 101.5 boys for every 100 girls. In China there were 116 boys for every 100 girls. No one is certain what happens to the missing girls. Some may be aborted after a sonogram reveals a female fetus, though this practice was recently declared illegal. The traditional practice of female infanticide, described decades ago by Pearl S. Buck and Somerset Maugham, may still exist. Some baby girls may not be reported in the census. Rural families are often allowed to have two children. When the first is a girl, some families wait to record the birth until the second child proves to be a boy. Some baby girls are abandoned.
The orphanage I visited is on the outskirts of a city, but the little girls were presumed to have come mostly from rural backgrounds. China is in the midst of what must be the largest rural-to-urban migration in human history. In recent years perhaps 100 million of China's 900 million peasants have moved to cities in search of jobs. The baby girls are left at railway stations, in parks, and in front of police stations. The police are supposed to search for the parents, but most searches prove fruitless. The boys in the orphanage are for the most part severely handicapped, but they are often not abandoned, and may have family contact and visits.
Newly arrived infants are placed in a separate small room, which held about ten baby girls during my visits. Two or three staff members--untrained, minimally paid women from nearby villages who were struggling to support their own families--were on hand for the infants. The babies were cuddly, cute, and alert.
Adoption is not unusual in Chinese tradition. I have known several infertile urban couples who adopted a child from one of their married siblings. In rural areas, despite the economic value placed on boys, families without female children have sometimes adopted little girls. The current one-child-per-family policy makes domestic adoptions more difficult, however. A couple must be childless and at least thirty-five years old before regulations permit them to adopt. But the pediatrician in charge of the orphanage told me that "normal" infants do find new homes. Some forty babies had been adopted the previous year, more than twenty of them by foreigners and the rest, presumably, by Chinese. I watched one day as Susan Lee, a single Chinese-American woman who works for the Federal Aviation Administration, in Washington, D.C., met her new daughter, Rachel, then eight months old. The baby had been in the orphanage since only a few days after she was born. When I had dinner with the new family a few days later, Rachel, who had been alert and curious when I first saw her but had been unable to hold up her head, was already discernibly stronger.
Babies who are not adopted are eventually moved out of the infant room into what the foreign women call the toddlers' room, a much larger space with six rows of eight cribs each. Staffing is minimal there--three or four women for forty-eight children. The quality of care precipitously declines. It is almost impossible for the volunteers to guess the ages of the children. Many suffer such serious developmental delays that they appear and act much younger than they are. Children who have just been moved are generally placed in the middle two rows. They are given bottles but scant assistance in feeding, and the schedule is rigid. Some of the children grab their bottles and eat lustily, and some--often the same ones--demand attention, crying, spreading their arms to be held. Their eyes beg for human warmth and affection. Others are already passive and withdrawn. Their bottles lie untouched, as though they are too weak, too indifferent, or still too young to make the effort. When feeding time is over, even the unfinished bottles are collected.
For the most part those who struggle and survive are eventually moved to the first two rows, although there are no hard and fast rules. When passive children become weak, they are moved to the last two rows--by whose decision or according to what criteria, we never learned. In the months that I visited the orphanage, from October to December of 1994, I never saw the children in these cribs being fed. Christine, who has been visiting for more than two and a half years, has sometimes seen the children fed, but has never seen any of them recover. Rather, she has watched them disappear, to be replaced by new arrivals.
What Westerners call the dying room is tucked away outside, adjacent to the place where sick children are tended. Different babies were there each time I visited, so stiff and quiet, their breathing so faint, that the end could not have been far. A couple had uncorrected cleft palates. They were not being tended, nor was there any obvious sign of medical treatment.
Christine has come to accept the deaths. She has to in order to work there. She visits the dying children each week, taking a mental count, but she never touches or holds them. She feels that such human contact would be cruel to children who have never known warmth or affection or holding, and would perhaps prolong their dying. Instead she gives all her energy and unconditional love to the little ones who respond to it energetically. She and other volunteers cuddle and feed and heap copious praise on the children, who light up in their presence. A Christian-based group also visits weekly, and so do Chinese students from nearby universities. When I visited, a team of doctors from Hawaii had recently assisted Chinese physicians in performing surgery on some of the children, and the pediatrician in charge of the orphanage was soon to receive several months' training in Hong Kong, where orphanages are exceptionally well run. The situation in the orphanage, most of the foreigners seem to agree, is already several times better than when they began volunteering.
The deaths of helpless children are haunting. We need to know how innocent babies can deliberately be allowed to die. Since my visits several exposés of Chinese orphanages have received widespread publicity. Last June the independent British television station Channel 4 ran a documentary called "The Dying Rooms," filmed by three journalists posing as workers from an American orphanage. They were graciously welcomed into at least one of the institutions they visited, as Christine and many other foreign volunteers have been. Last August, CBS's Eye to Eye also ran a segment on Chinese orphanages, incorporating excerpts from the British program and interviewing both its producers and Chinese officials. The footage is shocking, but what it shows is familiar to anyone who has visited the orphanages. Kate Blewett, one of the producers, is understandably distraught, outraged at what her investigation unearthed. The Chinese officials do not come off well, particularly when they deny the existence of what the camera has already revealed--such as dying rooms. This past January, Human Rights Watch/Asia published a lengthy report asserting that thousands of children in Chinese orphanages have died of starvation and medical neglect. And both Channel 4 and CBS's 60 Minutes have done follow-ups to the latest exposé. Again, the Chinese government's response has been defensive and unconvincing. "Dying rooms do not exist in China," the Foreign Ministry spokesman Chen Jian has asserted. But they do exist. I visited one six times over a period of a few months.
The official response to all these exposés highlights the painful quandary confronting Americans concerned with human-rights abuses in China. In the long run public revelations about China's orphanages may encourage the Chinese government to ameliorate the situation. In the short run, however, the plight of children already in orphanages may worsen. Since the Human Rights Watch/Asia report some American would-be parents of Chinese baby girls have been told to postpone their trips even when the adoption procedures are so far along that the new families already have pictures of their future daughters. Some hoping to adopt Chinese babies are afraid that with continuing adverse publicity China may halt adoptions altogether. Visits by Christine and other foreign volunteers had been temporarily suspended at the time of this writing, although they believed that they would be allowed to return soon after the Chinese New Year, on February 19.
That is why Christine is so reluctant to let me use her real name. "I would be devastated," she wrote me, "if the result of any of my actions would deny these children the few pleasures in life they now enjoy." Her concerns are shared by many foreign volunteers in China, who recognize the world's right to know but believe that change is best effected on the ground, through quiet cooperation rather than confrontation. But the exposés have demonized China just as U.S.-China relations are settling into a more troubled period. American public opinion toward China has typically swung between extremes of admiration and mistrust, as we project our own hopes and fears on a country we have consistently misunderstood. China is never as good or as bad as we think it is.
The foreigners who visit the orphanage every week do not claim to understand what is happening there. Each has had to come up with her own tentative, often unsatisfactory explanation and way of coping. Valorie Stackpole, the wife of an American businessman in China, still wonders about the real value of what she is doing--whether the few hours of play and nurturing she is able to give the children each week have any real effect. She questions whether outsiders can or should try to change a 5,000-year-old culture. Perhaps, she thinks, the visits are of more benefit to the foreigners, who are trying to help, than to the Chinese, who have such difficulty accepting our charity. She points out that the death of a child is never pretty, and urges me to visit the Children's Hospital in Washington, D.C., where I live. Conditions are modern and sterile there, but the sight of abandoned babies is no less tragic. Part of the reason she goes to the orphanage is that she believes her visits serve as a moral example to the Chinese staff, teaching that even handicapped, abandoned children deserve nurturing and love.
One woman who was among the first volunteers in the orphanage bristles at the suggestion that children are being allowed to die. She does not believe it, and wishes I had not even raised the question.
Bobbie Boudreau, a specialist in child development who taught at the University of Cincinnati before her husband's job brought her to China, and who is now a regular visitor to the orphanage, recalls the lessons in detachment she once taught her college students. How, without detaching, can people whose daily work is tragedy return home to normal and happy family lives? Perhaps the apparent indifference of some on the orphanage staff is instinctive detachment, the preservation of emotion for their own poor and needy families. Boudreau believes in the value of training.
"Why don't they just kill them?" an American friend who had spent years in Asia wondered angrily. "We are kinder to our animals. At least we put them out of their misery."
MY own search for an explanation has taken months. After my initial recoil from the dying children, I determined to give something to every child on subsequent visits to the orphanage--to hold and touch each one, and to feed the ones who could be fed. I stroked the hands and faces of the children who were dying and prayed that they be taken quickly, without pain, and that China would find a way to end this needless sacrifice of life. Only one of the dying children showed any sign of response. "China has too many children," a staff member said to me bitterly as I stood by the cribs.
I called upon Chinese friends for explanations, wondering whether the deaths were rooted somewhere in Chinese culture, perhaps in a different conception of what it means to be fully human. I have never known a Chinese to have moral qualms about abortion. In the Chinese view, fetuses are not yet human. Families do not traditionally celebrate a new birth until the baby is a month old. Historically, infant mortality was high in China, and the child was particularly at risk during the first month of life. Only when a child was past the maximum danger point was its arrival noted ceremonially. Too, the family is all-important in China; identity is embedded there. Perhaps children without families are denied the right to full humanity.
The pediatrician in charge of the orphanage would not discuss the deaths. The numbers were confidential, she told me. Chinese friends agreed that the deaths had cultural roots, and they assumed that the children being allowed to die were handicapped. Had not the director of the orphanage assured me that the normal babies were adopted? Burton Pasternak, an anthropologist who has spent time in Chinese rural areas, has been struck by how successfully people with Down syndrome and minor handicaps are integrated into village life. But for years Chinese friends had been telling me that severely handicapped infants--those with incapacitating infirmities requiring full-time care--are routinely allowed to die. "Everyone knows that a newborn baby will die after three days without feeding," one reminded me.
In the Buddhist tradition a severe handicap would be unmistakable evidence of a heinous crime in a previous life, for which the handicap was punishment. Better, then, to let the child die and look forward to the next reincarnation. Its crimes had been expiated. The next life would be better. In the Confucian tradition a severely handicapped child would be incapable of fulfilling the immutable demands of filial piety and thus unable to behave as a proper human being.
A doctor I know, a man of great compassion, reminded me of the history of political oppression in China. The best of his people have suffered the most egregious persecution, he pointed out. If the very best are persecuted, does it not follow that those of so little official worth--the handicapped and abandoned--should be allowed to die?
My discussions with Chinese friends made clear both the absence of a concept of equality in Chinese culture and the fact that the handicapped are even lower in the social hierarchy than girls. But the tragedy of China's orphanages cannot be fully explained by Chinese culture. My friends assumed that only the handicapped were being allowed to die, but many of the dying children had no apparent handicaps, whereas most of the older children did. The children's handicaps were not the full explanation for why some were being allowed to die.
At an elegant dinner party in Washington a few weeks after my return I was seated next to a child psychiatrist. I told him what I had seen. "In a holocaust or war," he said, "you do not put the best surgeon in the operating room. You put him at the entrance. His job must be to decide who can be saved and who cannot. The behavior of the children you describe was so profoundly autistic that even if by some miracle they were suddenly to receive twenty-four-hour loving, mothering care, they could not have been saved." The orphanage was practicing triage. My attempt to offer comfort to the dying had been more for my benefit than for the children's, he said. They were too withdrawn to understand.
WHAT is happening in China has parallels in the United States and elsewhere in the West. The first orphanage in the United States was founded in 1729 by an Ursuline convent in New Orleans, after an Indian attack left many children without parents. But the history of our orphanages, and of our treatment of homeless and indigent children, has not always been commendable. Early in this century, when systematic research on foundling homes began, investigators discovered alarmingly high death rates in the first year of the institutionalized children's lives--71 percent in one of Germany's great foundling homes, 90 percent in Baltimore, probably 100 percent at the Randall's Island Hospital, in New York City. Many of the children who lived suffered devastating physical and psychological damage.
René A. Spitz, in the mid-1940s, was one of the first to describe what happened to very young children who spent prolonged periods in institutions where they had no contact with their mothers. Previously happy and outgoing children from six to eleven months old became first weepy and then withdrawn, refusing to take an interest in their surroundings. After three months, Spitz wrote,
A sort of frozen rigidity of expression appeared instead. These children would lie or sit with wide-open, expressionless eyes, frozen immobile face, and a faraway expression as if in a daze, apparently not perceiving what went on in their environment. . . . Contact with children who arrived at this stage became increasingly difficult and finally impossible.
Many were unable, or refused, to eat. Spitz described the syndrome not as autism, which experts now believe to have physiological causes unrelated to maternal care, but as anaclitic depression. In one institution nineteen of 123 children studied suffered severe anaclitic depression, and another twenty-six exhibited the syndrome in a milder form.
In even the best-equipped facilities and under the most hygienic conditions children with anaclitic depression are highly susceptible to infection and illness. Thirty-four of ninety-one children whom Spitz, in one study, observed in a foundling home over a two-year period died of diseases ranging from intestinal infections to measles.
Much of what we know today about infants' need for love and stimulation, and about children's failure to thrive in their absence, can be traced directly to studies that began in foundling homes. Children are vitally dependent on the tenderness, affection, and stimulation that we associate with maternal love. Revelations of what happened to children in Western institutions led to "child-rescue" movements, the introduction of foster care, and the establishment of "anti-institutional institutions." Spitz and others found that up to a certain point the effects of the absence of maternal love are reversible. The baby's psychic wounds may heal, but only with the addition of loving, motherly care. In all but exceptional circumstances (and in the United States the exceptions are increasing--see "When Parents Are Not in the Best Interests of the Child," July, 1994, Atlantic) the best solution for children without parents is adoption.
As the movement against the warehousing of children succeeded, and as institutions themselves improved, psychiatrists were rarely confronted with children who had never been held or loved, and the term "anaclitic depression" receded from the psychological literature. But everything about the demeanor of the dying Chinese children is consistent with Spitz's description of the progression of profound infant depression. So is the fate of the children. Shortly after my last visit to the orphanage, as fall was giving way to winter, Christine returned to discover that sixteen children were gone. She does not know what happened to them. The history of orphanages in the United States suggests that even a minor infection could have swept them away.
Western experts were discovering what Spitz described as the "evil effect" of childhood institutionalization in the mid-1940s, just as the Communists were coming to power in China. Child psychiatry had not yet developed there, and the entire psychiatric profession was ultimately discredited under Mao's regime, which often treated mental illness as a failure of ideological education. During the Cultural Revolution, when most intellectuals were persecuted and physicians were sent to the countryside, the fledgling psychiatric profession was devastated. Only in recent years has it begun to revive. Only in recent months have I seen references in the Chinese press to a childhood illness resembling Spitz's anaclitic depression or the autism described by Bruno Bettelheim and others. The Chinese term means "the syndrome of isolation and loneliness."
What if ignorance and poverty are primarily responsible for the deaths of Chinese babies? What if we accept as truth (because it is the truth) the statement by China's Ministry of Civil Affairs, which is responsible for the administration of orphanages nationwide, that "China is a developing country which has 70 million people who still do not have enough to eat or wear, and it faces many difficulties in raising and educating handicapped children and orphans"? What if neither the pediatrician in charge of the orphanage nor her staff have been introduced to the literature on the psychological effects of institutionalization on infants?
If we accept that the deplorable conditions in China's orphanages result from both poverty and the past harassment of the psychiatric profession, then perhaps we can find ways to share with China what we have learned from our own history of failure to nurture abandoned and orphaned children. Many in China, including some officials at the Ministry of Civil Affairs, continue to welcome our cooperation. Chan Kit-ying, a social worker from Hong Kong, has helped local Ministry of Civil Affairs officials in Nanning, Guanxi; a Nanning orphanage; and the Hong Kong orphanage Mother's Choice to introduce foster care, train orphanage staff, and connect the Nanning orphanage with international adoption agencies. The benefits to the children have been stunning.
For foreigners to have a lasting effect on the situation in China's orphanages, more trained people like Chan Kit-ying will have to be willing to work on the ground, in China, cooperating with Chinese officials and orphanage staff. But the learning process will be a lengthy one. Chinese orphanages will not improve overnight. In the meantime, both China and the United States have regularized the procedures for adoptions. Michael Chang, of the American consulate in Guangzhou, where immigration permits are issued, reports that adoptions of Chinese children by U.S. citizens have approximately doubled in the past year, to about 250 a month, and he expects the number to keep growing.
Within a generation Chinese men will be suffering from a shortage of women to marry, and little girls will be highly valued. Perhaps by then China will have had its own movement against the institutionalization of children.
The Atlantic Monthly; April, 1996; In a Chinese Orphanage; Volume 277, No. 4; pages 28-41.