We Live in a Different China

We are born here, we get old here, we get sick here and we die here. But we are not from here. We are the foreign residents of China, our lives here forever temporary, no matter how long they last. We give birth here but our children are not Chinese. We get old here but never retire. We have heart attacks or get cancer here, and whether we survive or not, we must return home. No matter how much of our lives may have been here, foreign residents in China can not be buried here. We will all leave eventually.

You see us in the street or in your city but we live in a different China. No matter how good our Chinese or how well we’ve integrated into our communities, no matter who we’ve married or how long we’ve been here, for the most critical stages of life, we can always go back to our bubbles.

Birth

If China and the world agree on anything, it’s how to make a baby, but once that’s done, differences quickly arise. Pregnant Chinese moms are often cautious and treated delicately; in North America, Europe and some countries, women have run marathons while eight or even nine months pregnant.

Having A Baby In China.com slips into that gap, trying to bridge the cultural differences between the individualistic western approach to pregnancy and birth – where people talk about “the birth experience” – and the top-down approach of most doctors and hospitals in China, where being pregnant and delivering a grandchild is, as one foreign birth worker described it to me, almost considered a job.

“Having a baby overseas can be scary!” the website reads. “WE’RE HERE TO HELP.” I do not have kids, or know anything about having them, and even though many of my foreign friends have had kids in China, the internet was my first resource for information on the first stage of life.  

Started by an American couple in Tianjin with five kids (four born in China), Having A Baby In China includes a weekly podcast; a section of Chinese pregnancy vocab from breast pump (吸奶器) to umbilical cord prolapse (脐带脱垂); and a 199 RMB course  (“Our goal is ‘Peace of Mind for the Expat’ as you experience the amazing joy of giving birth in China”) that addresses topics such as ‘Choosing a Hospital in China’ and ‘Advocating for yourself During Pregnancy in China’.

The site is a glimpse into what’s important for foreign would-be moms and couples, and how some are trying to recreate the western experience — The Birth Bubble — in Chinese hospitals.

Enter the foreign doula.

*

As an idea, the doula goes back to the beginning of history, when experienced women and midwives would help others through pregnancy and birth. As a modern concept, the idea of the doula — a Greek word for female servant, coined in the 1980s — is less than fifty years old, started by American doctors who recognized that women who received physical and emotional support during their pregnancy and childbirth had better outcomes.

As an idea in China, it’s just beginning to take hold.

“There are about six of us,” Ruth Greene, an American doula in Qingdao, tells me. “I keep saying there has to be more. I constantly try to seek them out. We just added another one in Beijing two months ago, so that was really exciting.”

The path to being a doula in China looks like this: have a child here, become a resource for other pregnant moms by sharing your hard-earned information, and then formalize the experience with an international certification.

Greene, who has four kids, received certification in 2014, and has been helping new moms navigate the Chinese birth process since then. She, like most of the doulas, speaks fluent Chinese, including medical terminology related to pregnancy and birth.

Andrea’s path is similar. She moved from Germany to Ningbo, on a gap year in 2004 and has been there ever since. Her first child, a daughter, was born on the way to a Shanghai hospital, in a car at a rest stop on the side of the Hangzhou Bay Bridge.

Not wanting that experience again, she checked into a Shanghai hospital early for her second child, and during her stay, began a WeChat group for foreign moms in Ningbo. The technology, new at the time, finally gave her the opportunity to connect a lot of people in a single group — previously, it was one-on-one SMS messages.

The group morphed into a pregnancy center, where she has helped new moms with breastfeeding and post-partum depression, and finally a doula certification in 2020.

Their role is somewhere between translator, advocate and coach for the mom. They help at ultrasounds and sonograms, and even at the actual birth (which they sometimes attend by WeChat video call), but they are not medical professionals.

“I help them prepare for their birth,” Greene explains. “We walk through what the couple wants for their birth. C-section, a natural birth, an induction… We walk them through those decisions, and then I attend the birth in whatever capacity is possible for the situation.”

It’s also the doula’s responsibility to tell a client when a birthing method that might be common in their own country, like having a child at home, is strongly discouraged in China, or support the nurses and midwives when the mom wants to give birth in a different position than just laying on her back on the bed.

Andrea tells me a story about how the Chinese love for standardization and fixed procedures sometimes clashes with what the mom actually wants. She had a client who was a midwife herself, and wanted to move around during labor and then choose a birthing position she was comfortable with.

“But in China, they tend to just ask you to go to the bed and recline,” she tells me. Woman on her back, giving birth, like you see in movies — “this is the standard setting.” It’s what the nurses and midwives are trained in. They rarely see other positions.

“This woman decides to sit on a birthing chair,” she recalls. “The midwife (who worked for the hospital) got very confused, about how to sanitize the woman, how to cover her.” She spent a lot of time thinking about how to follow her protocol; with the woman in a chair, she couldn’t handle it. She consulted the doctor.

“Just take the situation as it is,” Andrea told her. “The mom doesn’t want to go to bed. She feels comfortable like this. So just, you know, get on your knees and help her to have this baby.”

In the end, everyone else was out of the room when the baby was born. Andrea caught the baby herself. “The mom was fine, the baby was fine,” she says. “But the midwife was stuck somewhere because of what she learned or what she’s not used to.”

“She’s never been trained on that,” Andrea says. “The standard protocol is being on the bed, and Chinese women just follow the instructions.” But the birthing chair didn’t fit the standard Chinese birth method. It was totally new. “The midwife couldn’t handle this new situation,” Andrea tells me. “It’s a cultural difference. This is still a challenge for us when we talk to Chinese doctors or midwives.”

The doulas work in both public hospitals, if the doctors are welcoming (they usually like the free help, though the doulas official status is ambiguous) and the couple can’t or doesn’t want to pay the high fees of private clinics; and in the private sector, where a fancy hospital’s checkups and birth fees can cost over 100,000 RMB.

“Chinese hospitals have zero tolerance for death,” Jacquelyn Carman tells me. Carman and her husband started the website I landed on, and are at the center of the foreign birth community, which exists almost exclusively online. “That’s great,” she says about the focus on moms surviving childbirth, “but the mom’s feelings and individual experience are not necessarily their first interest. This is where the cultures clash.”

“We want to be able to make our own decisions and we want to — it sounds a little strange — enjoy the pregnancy experience. We want to at least feel like we’re heard,” Carman says. “How the individual is feeling through this process is not the number one priority in China.”

Greene goes farther, saying that the birth experience can be traumatic for the mother. “Decisions and authority are typically taken away from the mom,” she says. “If they voice any objection, they are seen as being troublesome or even valuing their own feelings over the safety of the baby.” The undermining of confidence is a major factor in postpartum depression, says Greene.

She relates a story in which a pregnant mother was left alone in a room, not monitored, not allowed to have her husband with her, and “in so much pain she thought she might die — but didn’t have the strength to press the call button.” After the birth, the mother was told, “this is just part of the birth, you must 吃苦,” says Greene. “She carried that fear and pain for years.”

Today, Greene and Andrea are both in the early stages of formalizing their community-led experience into official businesses, though they emphasize that their passion for improving birth experiences is the driving factor over any financial potential. Often, they are not even paid for their services.

I ask Greene what she wants the outcome to be for foreign moms having kids in China.

“It’s the same for every mom,” she answers. “That they would be respected as human beings, not just a baby incubator.”

Illness

Aitor Olabegoya had just registered his marriage when a kite string slit his neck wide open.

The Spaniard, then in his thirties, was driving a scooter home from the wedding office in Beijing, his new wife on the back seat. They were both still in their wedding clothes. As the couple approached Chaoyang Park on the Fourth Ring Road, a taut string slammed into him.

The string paused for a second in the buckle of a bag across his chest before jumping up to his neck. As the scooter moved forward, the tension increased and the string cut into him. He felt nothing. By the time he stopped, onlookers were staring in horror. A man flying a kite in the park had been reeling it in at too low of a height at the exact moment Olabegoya was driving by. He took a selfie with his phone to see what had happened. His neck was sliced from side to side.

*

We can be divided into many different demographics, many different classes, but what level of access we have to health care is almost a defining feature of foreign life in China.

As long as we’re working — and almost all our existence here depends on working, for visa reasons — we all have Chinese medical insurance (医保). We can visit public hospitals the same as any Chinese citizen, though figuring out what they specialize in, how to run the maze, how to get an appointment, and how to communicate with the doctor are just the beginnings of our problems. Doing it while probably sick and vulnerable is really too much for most of us.

Entrance to the Medical Bubble, where doctors speak dozens of languages, appointments can be made by phone, and the staff can handle everything from a newborn to near-death, is expensive. Olabegoya was paying 15,000 RMB a year for private medical insurance, the key that unlocks this bubble, when his accident happened. Top-level insurance, which might include medical evacuation by air to another country in case China can’t treat you, can cost several times more. 

It’s not that we doubt the skills or knowledge of doctors in China’s major cities; many of my friends use the public hospitals for routine medical procedures. But when something goes really wrong, we want the comfort of being able to communicate (if our Chinese isn’t good enough) or the reassurance of a shared cultural background and shared medical expectations (even if our Chinese is good) — if we can pay for it.

Olabegoya, a chef with a decent income, could afford it. So the day of the accident, he held his neck wound closed with one hand and drove the scooter with his other hand, his wife on the back in her wedding dress, to Beijing’s United Family Hospital.

*

When it opened in 1997, almost twenty years after its American founder, Roberta Lipson, moved to Beijing, United Family was the first foreign-invested hospital in China. Today, it has hospitals in Beijing, Qingdao, Tianjin, Shanghai, Guangzhou and Shenzhen, and a medical center in Bo’ao.

UFH’s original Beijing hospital has more than 25 medical departments, including 24-hour emergency facilities and operating rooms equipped to handle surgical trauma, heart attacks, strokes and brain hemorrhages. Three of its four emergency medicine physicians are American. Its nurses speak fluent English. And it’s just one of several international healthcare operators in China.

In 2023, Singapore’s Parkway Pantai (百汇医疗) opened a 450-bed Shanghai hospital, following Jiahui Health’s (嘉会医疗) 500-bed international hospital a few miles away, funded in part by the Singapore government’s investment firm and a private equity company. In Shanghai alone, other options include Global Health Care (全康医疗), DeltaHealth (上海德达医院), Raffles (莱佛士医疗) and Columbia (哥伦比亚中国).

They are not aimed only at foreigners — the few hundred thousand foreigners in China are not nearly enough to support them alone — but they are almost always the first stop for foreigners in a medical emergency. 

*

Olabegoya was quickly rushed into surgery. Doctors sewed his neck back together with 47 stitches. The rough cut stopped just short of his carotid artery and jugular vein, but now infection from the dirty string, among other complications, was a serious risk. The hospital kept him in intensive care for two days before discharging him. It took him three weeks to recover. Insurance paid the 160,000 RMB bill. He calls himself blessed to have had insurance.

Two ragged lines circle his neck, from his Adam’s apple outward. Doctors offered cosmetic surgery to remove the traces of that day but he keeps the scars as a memory.

They never found the person flying the kite.

*

Olabegoya’s first instinct was to go to a private hospital, where he knew he would be treated immediately. He worried that, even with a slit neck, there might be worse injuries at the public hospital and he would be stuck in line.

It’s impossible to second-guess someone in his situation, but as we spoke, I wondered what might have happened if he hadn’t had insurance, or if he had gone to the closest public hospital instead. So after talking to him, I began asking around among my friends for people who had been in a similar life-or-death situation but chose a different path. Mark came forward. 

Mark abhorred The Bubble. An American professor at a university in northern China , he started studying Chinese as a teenager. He has lived in China on-and-off since the early 1990s and teaches Chinese students, in Chinese.

“Six months ago, if you had called me an expat, I would have objected strongly to the suggestion,” he told me recently. “I never wanted to have anything to do with expats… I’ve always idealized the idea of working with Chinese academics as equals.” He speaks derisively about The Bubble, about the foreigners in Sanlitun who don’t speak any Chinese.

A few months ago, that all changed.

A routine health check at a private hospital, an unexpected gift from his partner’s employer, found traces of a recent major heart attack — a heart attack he didn’t even know he had had. His initial bemusement and disbelief at the diagnosis faded quickly when, after being transported to one of the country’s top public cardiovascular hospitals by ambulance, the disinterested doctor told him he needed immediate, life-saving treatment.

But the doctor wouldn’t provide the treatment. In order to receive it, he would have to be checked in to the hospital. When he asked when there would be a bed available, the reply rattled him to his core. “I’m not a fortune teller,” Mark recalls the doctor answering before brushing him off for another patient.

The casual rejection from the doctor left him feeling utterly helpless and disillusioned. Fearing for his life, “there was no suggestion of trying another Chinese public hospital,” he told me. Mark and his Chinese partner quickly evaluated their options, and chose a well-known international hospital, where he received life-saving treatment. He did not have private insurance and the hospital fees came to 150,000 RMB. He paid out of pocket.

Mark is no stranger to the Chinese medical system. In his early days in China, he volunteered as a translator at a public hospital on the east coast. Now in his fifties, he speaks better Chinese than the vast majority of the foreign residents in China, is completely integrated into society, and has some social prestige as a professor. He always assumed that if he encountered a truly life-or-death situation in China, he would be okay.

He has no illusions that things would have been easier in America, where, without insurance, an emergency like this could have bankrupted him. Mark is still unnerved by the first doctor’s indifference but says, “in a way, thank goodness that it happened in China.” He knows he is privileged by “unusual resources” to be able to afford the type of treatment he received.

He goes to public hospitals for his follow-up care. He has made a full recovery and continues to teach.

Like Olabegoya, I was a chef when I came to China in 2005, working at a five-star hotel in Shanghai. I was young and the salary was low but the job included fancy health insurance, which was a luxury to me — until then, working in restaurants in America, I had not had insurance for years. I used my new Chinese insurance sparingly but enjoyed every visit to the doctor, at a private hospital in Pudong, knowing that someone else was paying the bill.

I left that job the following year, and I was back on my own, uninsured. For the next several years, I avoided doctors and hospitals, and hoped that nothing serious would happen to me. The Chinese hospital system was too complicated and I was too embarrassed to ask a friend to translate for me; the private hospitals were far beyond my budget. When I got sick, and I did, often, usually with stomach problems, I spent hours in the bathroom and prayed it would pass.

I woke up one night in 2009 with a severe stabbing feeling in my stomach. It was one in the morning. My wife at the time was deep asleep and just nodded when I told her I was going to the doctor. I didn’t have time to explain. This was not food poisoning or a simple stomach problem. I couldn’t pray or shit this away. I took a taxi to Parkway’s 24-hour clinic, doubled over in the back seat of the car.

I knew I couldn’t afford it but the pain was sharp and deep and I was scared. I didn’t have the money for Parkway — I was living on a writer’s small salary by then, after changing careers — but neither did I have the patience or Chinese skills to deal with a public emergency room.

In the end, I don’t remember what the diagnosis was, but after several hours of intravenous medicine and observation, the stabbing sensation went away. It was painful but thankfully not serious, and now my biggest fear was the bill. What had I done? I wondered, and how was I going to afford this?

The total came to something like 6,000 RMB, about half my salary at the time. It hurt my bank account but I paid it. When I left the hospital, it was sunrise, and I swore, from that day on, I would stop praying my illnesses away. I needed insurance. When I asked for a raise at the media outlet I was working for to cover insurance — 1,000 RMB a month — and the owner refused, I quit on the spot.

In retrospect, I didn’t consider the public hospital system. I was spoiled by that first year of private medical insurance and private hospitals, and scared of the horror stories about Chinese hospitals that circulated through the expat community (and may or may not have been true). I didn’t understand how the system worked until many years later, when I had more Chinese friends and, for a few years, even dated a Chinese doctor.

Today, I have insurance and I use it regularly. I have a long-term relationship with several of my doctors, and the pharmacists at my clinic know me by name. I can still barely afford it — several thousand RMB a month now that I am aging into my 40s — but for me, it’s non-negotiable. I know my situation is privileged, and that there are great doctors at many of China’s hospitals. But healthcare is one Bubble I won’t step out of.  

“I understand why most foreigners leave the country for serious medical treatment,” Catherine tells me. “Medical terminology is difficult to understand in our native language, let alone in a foreign language.”

She is the rarest of the expat community — a wise elder. Catherine has been through three of the four major stages of life in her 38 years in China — birth, aging and the death of friends. Now illness shadows her. She has stage four, triple-negative breast cancer, which has metastasized and spread to her colon.

She is comfortable dealing with private issues in Chinese. She has an entire network of family and friends here and abroad who provide support to her and her family. She has stayed in China for treatment.

Catherine is an exception of the highest order. When foreigners get seriously sick in China and it’s not an emergency that must be dealt with on the spot, like Olabegoya’s freak accident or Mark’s heart attack, we almost always leave.

We hear about them after the fact. They disappear from our WeChat groups and our social circles, and rarely come back. For the younger generation, it might be mental illness that sends them home, like in the case of Abe.

Abe was an acquaintance of mine who was convinced that a popular Japanese tonkatsu restaurant was selling sex services from the kitchen between the lunch and dinner shifts. When he brought up his theory in a taxi one day, we all laughed at him and moved on. When it became clear he was serious, we backed off and changed topic. That was the first sign something was wrong. A few months later, Abe disappeared back to America, supposedly diagnosed with paranoid schizophrenia.

For the older generation, it might be heart problems or cancer, like in Catherine’s situation. Her case is not as dramatic as a slit throat or a silent heart attack (though just as, or even more, serious); she has had time to consider her options. She could have easily flown to Hong Kong, Bangkok or even the U.S. (though her insurance doesn’t cover her there). But she stayed in Shanghai. Her roots here run very deep.

Catherine moved from the U.S. to China in the 1980s, first teaching English and learning Chinese in an inland province, before a life in the manufacturing industry. She traveled the country by bus and slow train in the 1980s from Heilongjiang to Xinjiang and Tibet, gave birth in the early 1990s in a Chinese public hospital, had a successful career in Shanghai and, after several decades in China, has aged into semi-retirement.

Catherine has good private insurance, but returning back to the U.S. would have been extremely difficult. Like most healthcare insurance sold to expats, Catherine’s insurance plan covers treatment in every country in the world except the U.S., where medical costs are extremely high and the billing system complex. In China, it covers the majority, if not all, of the fees at both public and private hospitals, and she receives treatment from both types of hospitals for her cancer. She does not have additional insurance for the U.S..

Neither is she scared by second-hand information about the pitfalls of Chinese hospitals.

“I've been working in Chinese hospitals for 25 years,” she tells me, sponsoring and supervising surgeries for orphan children with issues like cleft palate, spina bifida and heart valve problems through one of the non-profit organizations she works with. “I've seen the medical establishment here change and evolve over a long time, and I am aware of and pay attention to medical developments.”

She brings up her son’s birth in 1994, a 25-hour ordeal that ended in emergency surgery but left her with a good impression of Chinese doctors.

“The doctor had been doing this for 30 years and delivering, like, 20 babies a week,” she recalls. “It was great that I had a woman with that experience.”

Her cancer treatment takes place in a mixture of public and private hospitals, in and out of the Bubble — she is a highly educated and advanced consumer of healthcare in China, and knows how to find the right doctors at the right public hospitals, has the social connections to get access to them, when to do her own research, and when to reach out to specialists in the U.S. through tele-medicine.

She has connections overseas, with doctors and medical specialists in America who are able to offer second or third opinions, and help direct her care here through her team of Chinese oncologists and surgeons.

Catherine’s experience in the system, coupled with her relentless research and self-advocacy, has been paying off. Her diagnosis cannot get worse but she still has treatment options. The color has returned to her face and she is upbeat throughout our long conversation. Her doctors, at both the public and private hospitals, are optimistic about her future.

Aging

The older we get, the less China knows what to do with us.

Charles came to live in China for the fourth time when he was 52. He is a classic British gentleman and has run five-star hotels around the world for decades. Now 68, he has spent the past 16 years managing a prestigious hotel in Shanghai often used by the city leaders and high-ranking visitors.

Charles is active in the city, exploring its bars, restaurants and cultural offerings, and has a wide range of friends of all ethnicities and ages. He travels for fun in China and around the world, visiting wine regions. His apartment is very obviously a home and he cooks often for himself and friends. His mind is sharp and he is engaged with life.

But he shouldn’t really be here. He is too old.

*

Foreigners must be at least 18 years old to work in China. There’s no agreed-upon upper limit. Whether we must retire at 55 or 60, like Chinese citizens, is an issue for the courts. For now, Charles is protected by his green card.

In 2004, China began issuing permanent residence to a highly select group of foreigners. The threshold is high: we must have invested at least $500,000 USD in a Chinese business for three consecutive years; be married to a Chinese citizen; make a “significant contribution” to the country; or possess skills that are especially needed.

Charles has permanent residence. He is one of the few to possess it. By 2020, less than 17,000 of the green cards, recently re-branded “five-star cards” for a new design, had been issued. (In contrast, the US issued more than two million employment-based green cards in the same time frame.) The card gives him all kinds of benefits — no visa or work permit required being the biggest one — in line with what the government provides for its other citizens. But it puts him in a gray area when it comes to work.

When China began ushering in a wave of expats in the 1990s and 2000s, it didn’t expect us to stay. Our visas were always conditional and short-term, and when we got old, we just left. It made sense. China does not need more people, and especially people with escalating health problems. We didn’t ask to retire here, which if you are not married to a Chinese citizen, isn’t possible anyway; unlike many southeast Asian countries, there is no retirement visa in China. 

But the longer we live here, the more that’s going to change. Some of us have begun taking to the courts when labor laws say we should retire, according to law firm King & Wood Mallesons (金杜律师事务所). On the internet, others talk about how to recoup the 8% pension tax we pay from our salaries every month — a pension it’s possible to draw, after 15 years in China, but highly unlikely we will use, given the visa and health care realities.

The root of the inconsistency, according to the law firm, is that “The Regulations on the Management of the Employment of Foreigners in China provides that in China, the minimum employment age for a foreigner is 18, but there is no explicit provision to specify whether they shall be bound by requirements of the Chinese statutory retirement age.”

That question is left to the provinces or municipalities, and it's the gray area, along with his green card, that allows Charles to stay in China and continue working many years past the official retirement age. No one, not his human resources department, not the entry-exit bureau, has told him he can’t.

“Each year I get a one-year contract — and that’s because I want to — and it expires in summer,” he tells me. “Generally, in spring, they ask ‘Would you like to extend it?’. We just go through the process. So I’m assuming it will be the same process. I don’t see why not.”

Charles is old enough to be my father, the oldest friend in my social circle. He represents a possible path for my own future in China, and those of us who might stay longer than anyone expected — though none of my friends plan to retire in China. Talking about it with them feels ridiculous; leaving is assumed.

But then, we didn’t really plan to be here this long in the first place. Most of my friends came in their 20s, like me, and are now in their 40s, also like me. They came for adventure or work, and for myriad reasons, have made a life here. Many left in 2022, to Singapore, to North America, to Europe, but several have stayed.

They have been through the birth stage of life and now raise their children here, as second-generation expats. For the most part, they have settled down and moved into middle-age.

I met many of them through the music and nightlife scenes, and when we once cared about what DJ’s were playing in what club, now they talk about school fees and babysitting schedules.

But for many, their time is short. Wary of the public school system, they send their kids to international or bilingual schools, where school fees can run more than 300,000 RMB per year — for kindergarten. Without the support of an executive-level salary package, the school fees are what eventually drive them to leave China. The minute a foreigner has a child in China, the hourglass turns over and the sand starts falling. By the time their oldest child is ready for proper school, it’s time to leave. 

I don’t have kids, or any plan to make any, and so I remain here in Shanghai, watching my friends and their children slowly age out of China. 

*

Charles’ children, born in Africa during his time there, are both expats in their forties, one in Asia and one in Europe, with their own families. His marriage has run its course; now separated, his wife lives back in the UK.

Alone and with few bills, Charles doesn’t need a pension. We don’t talk about it, but at the time his green card was issued, the minimum salary requirement for an eligible employee was 720,000 RMB per year. He does just fine. Not that he wants to retire anyway. “I will keep on working. Not because I have to, but because I just enjoy what I’m doing.”

We tally up the years he’s spent working in China, starting in the late 1980s: more than two decades. He was in Hong Kong for the handover, in Shanghai for the Expo. “There’s so much positive happening in China now,” he says. “Those are moments in history.”

If he has any regrets about his forty-plus years abroad, or growing older in a foreign country, he does not let on. “It was a great way to see the world but at the same time to experience people,” he reflects. “I’ve always enjoyed history and geography, from an early age. Those two coupled together — what better job to have than working in this business.”

Mentally, he feels ten, fifteen years younger than he is. He does annual health checks in Thailand but goes to Chinese public hospitals for the type of routine medical care that his age demands: colonoscopies, prostate checks. He has lived away from his home country since the late 1970s. For him, home is wherever he is at the moment, and he doesn’t feel a need to go back or slow down, no matter the age.

“I live alone,” he says. “One day I’m going to wake up dead. I put it to the back of my mind, as I think all of us do. That’s why I’d rather be doing the things I’m doing, whether it be traveling, going on trips, seeing parts of China, parts of the world.”

He has considered the end as far as drafting a will and making a list of his computer passwords. “You can’t do anything about it,” he tells me. “Do you want to? If I look at my age and I look at other people of my age, am I envious or jealous of what they have?”

“No,” he says firmly. “I’ve done all the things I want to do.”

Charles has no concerns about the possibility of dying in a foreign country. “In 12 days’ time, I will be 69,” he tells me. “I have been blessed with my life experiences so far. Long may they continue.”

Death

Wu Qiong was conflicted. She had just picked up the American man’s ashes from the crematorium and was at the airport in Wuhan, the remains stashed in her carry-on suitcase. But she desperately had to use the bathroom. She debated what would be worse: leaving the suitcase outside the toilet and it being stolen; or potentially disrespecting the man’s memory by bringing him into the restroom with her.

“This is probably the first time you’ve been in a women’s toilet,” she remembers telling the suitcase as she wheeled it into the bathroom stall. The man, who had terminal cancer,  had died on Wudangshan while making a final, international pilgrimage. “Turn your head,” she said. “No peeking!”

That was her first case, in 2012, but not the last time she spoke to ashes. In her early years working for Roseates, a small agency that specializes in the repatriation of human remains from China, she used to ask the ashes if ghosts were real or not. She figured they would know. Wu has collected so many bodies of foreigners from across China that she has lost track of many of the specific details. Often, she would have to spend a night in a hotel room with the remains while waiting for a morning flight.

She wasn’t scared, she told me — death is not taboo for her — but she did want to settle the question. “If you are there, show me,” she would challenge the ghosts. She never saw one.

*

Wu, now 39, has helped repatriate the remains of foreigners who died mountain climbing in Tibet, been there to assist after a woman fell from the 22nd floor of a high-rise in Suzhou while trying to climb in through an outside window, and seen the results of a young Russian man whose body decomposed on a couch after an alcohol-related death. It happens more often than we imagine, up to five times a day, estimates the founder of Roseates, and the logistics are complex.

Since 1995, foreigners who die in China cannot be buried or have their ashes scattered on public land, except in extremely rare circumstances for people who have made a “special contribution” to the country. Instead, our embassies are tasked to contact the next of kin, who often then hire a company like Roseates.

Founded about 15 years ago by Belgian Wilfried Verbruggen, who Wu calls a father figure, Roseates’s services involve handling “the hospital, the Emergency Intervention Team, the hospital morgue, the Forensic Medical center, the funeral home, the crematory, the Public Security Bureau at local-, district- and city level, Civil Affairs, the Notary Public, the China Foreign Affairs, the Funeral Association, the local hearse company, the Quarantine inspection, the airport Customs, the cargo agent, the airline handling agent, and the consignee,” according to its website.

Verbruggen had been in the “import/export business”, as he called the international funeral director industry, back in Belgium, before a second career selling earth-moving equipment in Europe and Africa. But after moving to China in the 1990s, he reluctantly went back to repatriation of human remains after an embassy asked him for a favor. He has been handling death in China for a long time.

Verbruggen and Wu work in the Death Bubble.

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Death in China is a highly regulated business, with fixed prices for services — but not always for us. According to China Daily, the official price for embalming in China was 300 RMB in 2015 for Chinese citizens, but, Wu tells me, foreigners may pay inflated rates, particularly in rural areas where officials are not familiar with the process or regulations.

A typical repatriation, including embalming and airfare, can total six figures. I asked Wu to estimate what it would cost to get my body home to the U.S. if something happened to me — 120,000 RMB to the Atlanta airport, she told me. My family, in Miami, would have to figure out what to do with my body from there.

Not everyone can afford the steep bill, even when Roseates’s handling fee is just a tiny fraction of that high cost. Wu tells me about a case in which a young man from an African country was stored in the morgue for more than two years while his family back home raised money for the repatriation and the funeral. In another case, a deceased photographer’s embassy, unable to locate any of the man’s family, sold his expensive camera and used the proceeds to send his body back to his home country.

In an average year, Verbruggen, Wu and two other Chinese employees handle between 120 and 140 cases, less than one in ten of the foreign deaths in China, according to Roseates’s own estimate. Germany, the United States and the UK are the top destinations, though the company has sent bodies to more than 80 different countries.

Handling so much death, across all of China, Verbruggen recognizes quality and value, and Shanghai is the only city to have both, particularly in the professionalism of the embalming and the workmanship of the coffin, which in other cities or provinces might be nothing more than an unlined shipping crate designed to look like, but not function like, a real metal-lined coffin. “Shanghai is the best place in China to die,” Verbruggen says.

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Verbruggen, in his mid-70s, passed the company to Wu in 2023 and retired to Chengdu with his family. His own health issues, and the 24-hour/7-days-a-week demands of the job, gave him too much pressure, Wu told me. 

Wu considers her job a mission, a service to the families of the deceased, who have lost their loved ones in a far-off, foreign country. She hopes to continue in this work for the rest of her life. That could set up the potential situation of Wu or her colleagues having to carry her former boss’s ashes back to Belgium, should he pass away in China. (Verbruggen told me that if he dies in Belgium, he’d like to be buried, but if it happens in China, he wants to be cremated.)

It’s an awkward question to ask, but Wu puts me at ease. “We hope Wilfried lives another ten or 20 years, but we have to be realistic,” she says. “I could still be working then.”

For his part, Verbruggen is not too concerned. “Where I die, China or Belgium, is not important,” he says. “Just hope not to die in a hospital!”

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(A version of this article originally appeared in Chinese on 正面链接. It was edited by 于蒙, with illustrations by 陈禹, and visual design by pandanap.)