City of Immigrants

Like millions of others from all over China, public health professionals migrated to Tianmai throughout the 1980s, 1990s, and 2000s to pursue what residents called, in a purposefully American fashion, the "Tianmai dream" (tianmai mengxiang). Predating by several years the broader "China dream" (zhongguo meng) later popularized by current Chinese president Xi Jinping, the "Tianmai dream" was for my interlocutors a natural outgrowth of Tianmai's identity as a "city of immigrants" — a moniker that implied freedom, possibility, and openness. Many of those whom I met in Tianmai told me that they came to the city because they saw it as a beacon that would free them from the small, stifling world of guanxi obligations, family ties, and dead-end jobs that they felt awaited them in their hometowns. Several also told me that they came because Tianmai was less "paiwai" (excluding of outsiders) than other big Chinese cities with similar opportunities, such as Guangzhou, Shanghai, and Beijing. My non-Cantonese informants in particular found this diverse enclave in the middle of Cantonese-dominated Guangdong province to be a breath of fresh air in a context in which they otherwise felt excluded linguistically and culturally. Yet after settling into their new homes and new jobs, most of the public health professionals I knew then went on to exclude the majority of their fellow migrants from this Tianmai dream.

In this chapter I argue that in their attempts to serve a civilized immigrant common emblematic of the Tianmai dream — as well as to protect their own preferred identities as privileged members of this common — Tianmai's public health professionals built and maintained precarious spatial, legal, historical, biological, moral, and professional boundaries between themselves and the 12 million strong floating population (liudong renkou) of rural-to-urban migrant workers that dominated the city. In building these boundaries, they established the majority of the residents of Tianmai as a population that had to be governed — but one that would not and could not be a part of a common to be served.

The floating population and the civilized immigrant common reflected two sides of my interlocutors' "divided selves" (Kleinman et al. 2011). On one side was their past as members of poor peasant or worker families who toiled and suffered under a backward Maoist regime: the "population." On the other side was their future, as educated, cosmopolitan immigrants, living in a modern city that was uniquely free of the ghosts of a Maoist past: the "common." In this way, the migration of poor, rural people into the pristine modern city of Tianmai reflected a lingering fear on the part of that city's public health professionals that the side of their divided selves that they had left behind in the countryside would threaten the side that they had come to Tianmai to embrace.

The Floating Population

As of 2010, of Tianmai's estimated 16 million residents, 60 to 80 percent were categorized as floating — a term that describes the continuous movement of rural migrant workers from job to job and from the countryside to the city and back again. According to C. Cindy Fan (2008), as of 2006, official estimates of China's floating population totaled about 150 million people nationwide. Informal estimates that my informants gave me in 2014 put the number somewhere closer to 250 million and growing. Rural villagers fled the Chinese countryside in the 1990s and 2000s, drawn to the cities by factory jobs and a chance to take part in the economic reforms that followed Mao's death. Legal residency requirements, however, prevented most of them from settling down permanently. As holders of rural household registrations (hukou), rural migrants living in cities continued to be tethered to their hometowns.

The central Chinese government established the hukou system of household registration in the 1950s as a means of monitoring and controlling population mobility between the countryside and the cities. All citizens were assigned at birth either rural or urban hukou status and generally were eligible for only the welfare and social services provided in their hometowns. This meant that a large majority of Chinese people was systematically excluded from many of the benefits associated with urban citizenship, including health care (Chan and Zhang 1999; Solinger 1999).

Governments at the central and local levels relaxed hukou restrictions with the start of the reforms in the early 1980s and continued to modify the law to be more permissive in the decades that followed. Nevertheless, in the late 2000s urban hukous remained difficult to obtain — especially in the big cities and especially if one was not highly educated — and many rural residents who migrated to the cities remained excluded from the cities' benefits. Those who migrated to Tianmai without a hukou could apply for temporary or permanent "residence cards" that would qualify them for some of the benefits of urban registration, but migrants could get these only after going through extensive paperwork, meeting strict eligibility requirements, enduring long waiting periods, and often paying high fees. In addition, as Li Zhang (2001) has described, many migrants feared that they would be found out by birth control authorities and fined for violating the one-child policy if they attempted to register. As a result, despite official assertions that the residency system accounted for all migrants, much of the floating population remained unaccounted for. Although they made up the backbone of Tianmai's economy and the majority of its population, a large proportion of migrants were officially not there. And even where recent legal reforms began guaranteeing certain basic benefits for the migrants, laws were rarely enforced. For example, the state began granting certain limited legal rights to pensions (in 2006), health insurance (in 2008), and unemployment insurance (in 2013) to rural-to-urban migrants in the 2000s, but access and utilization remained quite limited (Mou et al. 2009; Lam and Johnston 2012; Magnier 2014).

One of the many implications of the hukou system was that Tianmai's public health professionals did not have to concern themselves as much as they otherwise might have with the mundane health concerns of its residents and in particular with the rising rates of chronic illness that were weighing down other health systems in urban China (He et al. 2005; Yang et al. 2008). Dr. Mi, a virologist, explained it to me this way: "Tianmai is a particular case because we depend on the wailai renkou [the outside population], but we don't take responsibility for their security. So if they get sick or old, or if they can't compete, they go home, and a new group of young people replaces them. So some...