1. Introduction
When the demand for health-care products fuels the market, it also creates opportunities for fraud. The global revenue of the health-care industry grew from USD 17.7 billion in 2017 to USD 53.9 billion in 2021 (Statista, 2022). As the health-care market expands rapidly, so does the problem of health fraud. China, the nation with the largest health-care market share (USD 18.6 billion) globally, released an official report suggesting RMB 8.4 billion had been prevented from being lost to health fraud in only three months (Ministry of Public Security, 2022). The COVID-19 pandemic has only exacerbated the issue, with the rise of Covid-related health fraud, such as vaccination scams, mask scams, and anti-Covid scams (Australian Competition & Consumer Commission, 2021, p. 12). Despite this, the understanding of this type of crime remains underdeveloped (Zhou et al., Reference Zhou, Xu and Wu2023).
The primary targets of health fraud are older adults and individuals with health-related vulnerabilities. Although there has been limited attention given to health fraud, studies have identified several types of vulnerabilities that contribute to it, such as emotional instability, cognitive decline, loneliness, and mental health issues (DeLiema et al., Reference DeLiema, Deevy and Lusardi2020, p. 864; Fan & Yu, Reference Fan and Yu2021, p. 230; Kircanski et al., Reference Kircanski, Notthoff and DeLiema2018, p. 327; Lachs & Han, Reference Lachs and Han2015, p. 878; Lichtenberg et al., Reference Lichtenberg, Sugarman and Paulson2016, p. 60; Shao et al., Reference Shao, Zhang and Ren2019, p. 225.) However, a focus on the causal relationship between vulnerabilities and fraud victimization can lead to stereotypes, stigmatization, and discrimination against victims (Carter, Reference Carter2021, p. 283; Cross, Reference Cross2016, p. 60; Cross, Dragiewicz & Richards, Reference Cross, Dragiewicz and Richards2018, p. 1317). To shed new light on the understanding of health fraud, Zhou et al. (Reference Zhou, Xu and Wu2023) promote the perspective of vulnerability manipulation, which stresses the significance of recognizing offenders’ intentional manipulation of victims’ vulnerabilities.
The current study utilizes the concept of emotional labour—a term originating from labour studies—to examine the tactics used by health fraud offenders in manipulating older adults’ vulnerabilities. Emotional labour refers to the management of one’s emotions as a means of production to achieve financial and organizational benefits (Hochschild, Reference Hochschild2012). Despite its relevance to the understanding of health fraud, the concept of emotional labour has received limited attention in criminological and socio-legal literature.
To explore the use of emotional labour in health fraud, the study focuses on the issue in China, which has the largest ageing population and has seen a rapid increase in health fraud incidents (Huang, Reference Huang2020, p. 68). The study collected data through 13 semi-structured interviews with secondary victims, 233 judicial documents, and 197 media reports. Results showed that health fraudsters often use three types of emotional labour to manipulate older adults, including the labour of anxiety relief, the labour of filial piety, and the labour of social networking. The findings of the study contribute to the understanding of health fraud manipulation tactics and bring new theoretical insights from labour studies to criminological and socio-legal studies.
2. Health fraud, older adults, and vulnerability manipulation
Health fraud refers to fraudulent schemes that exploit individuals’ financial resources by distorting the therapeutic benefits of health-care products or services (US Food and Drug Administration, 2021). Some common forms of health fraud include cancer-related fraud, anti-ageing fraud, diagnostic test fraud, weight loss fraud, and dietary supplement fraud (US Food and Drug Administration, 2021). The crime has caused a large volume of financial loss globally. For instance, it was reported that Americans lost about USD 108 billion to health fraud in 2018 (US National Health Care Anti-Fraud Association, 2021), while Australians experienced a 20-times increase in health fraud cases in 2019 (Australian Competition & Consumer Commission, 2021). Apart from the tremendous financial loss, the crime also contributes to imponderable harm to victims’ physical and psychological wellbeing, some even leading to suicide (Sarriá et al., Reference Sarriá, Recio and Rico2019; Sina News, 2021).
The primary targets of health fraud are older adults and individuals with ageing-related health vulnerabilities. From the physical perspective, declining physical functioning (e.g. reduced cognition, vision, and hearing) may disadvantage older adults’ capacity to recognize fraudulent information (James, Boyle, & Bennett, Reference James, Boyle and Bennett2014, p. 107; Lachs & Han, Reference Lachs and Han2015, p. 878). Financially, older adults tend to have more accumulated wealth and decreased numeracy skills, making them attractive targets for motivated fraudsters (Cohen & Felson, Reference Cohen and Felson1979; DeLiema et al., Reference DeLiema, Deevy and Lusardi2020, p. 864; Shao et al., Reference Shao, Zhang and Ren2019, p. 225). Socially, older adults usually experience a higher level of loneliness and greater demands for social support, which enhance their exposure and proximity to criminogenic environments (Alves & Wilson, Reference Alves and Wilson2008, p. 63; Cross, Reference Cross2016, p. 60; Du, Reference Du2019; Holtfreter, Reisig, & Pratt, Reference Holtfreter, Reisig and Pratt2008, p. 189; Xu, Reference Xu2019). However, over-focusing on the causal relationships between vulnerabilities and fraud victimization may contribute to limited and even biased understandings, such as stereotyping, stigmatization, and victim-blaming (Carter, Reference Carter2021, p. 283; Cross, Reference Cross2016, p. 60; Cross, Dragiewicz, & Richards, Reference Cross, Dragiewicz and Richards2018, p. 1317).
Instead, vulnerability manipulation, the perspective highlighting offenders’ manipulations of victims’ vulnerability, offers a more victim-friendly narrative to understand health fraud victimization. By incorporating socioemotional selectivity theory, Zhou et al. (Reference Zhou, Xu and Wu2023) found that fraudsters strategically exploit older adults’ ageing-related vulnerabilities, including their reduced ability to collect information, their comfort-driven social preference, and their positivity-driven emotional preference. However, the study was limited in its scope, as it primarily focused on introducing the concept of vulnerability manipulation and did not delve into the specific manipulation tactics used by the offenders. In a nutshell, the current study extends the vulnerability manipulation perspective by incorporating the concept of emotional labour and examining the tactics used in health fraud manipulation.
3. Emotional labour: a fresh concept in criminological studies
Emotional labour, first introduced by Hochschild (Reference Hochschild1979), refers to the effort made by employees to regulate their emotions in order to meet the expectations set by their employers. The concept highlights that the provision of emotional services is an integral part of the service itself (Hochschild, Reference Hochschild1979, p. 572). Therefore, people’s emotion could not simply be regarded as a result of their work and labour, but a means of production (Brook, Reference Brook2009, pp. 532–3). Since its inception, extensive research on emotional labour has been conducted in the fields of labour and management, covering various domains including businesses and public sectors (Bono & Vey, Reference Bono, Vey, Hartel, Ashkanasy and Zerbe2005; Hülsheger & Schewe, Reference Hülsheger and Schewe2011; Humphrey, Ashforth & Diefendorff, Reference Humphrey, Ashforth and Diefendorff2015). For instance, a significant amount of research has focused on the impact of emotional labour on employees’ job satisfaction, job performance, and psychological wellbeing (Bono & Vey, Reference Bono, Vey, Hartel, Ashkanasy and Zerbe2005; Hülsheger, Lang, & Maier, Reference Hülsheger, Lang and Maier2010; Hülsheger & Schewe, Reference Hülsheger and Schewe2011; Morris & Feldman, Reference Morris and Feldman1996; Philipp & Schüpbach, Reference Philipp and Schüpbach2010). Other studies have explored the dynamic relationships between emotional labour and customer feedback (Korczynski, Reference Korczynski2003, p. 55). However, relatively few studies have extended beyond the realm of labour and management research to examine the role of emotional labour in criminological and socio-legal studies.
The concept of emotional labour has shown its potential to be applied in criminological and socio-legal studies. In the book Emotional Labour in Criminal Justice and Criminology, Phillips et al. (Reference Phillips, Westaby and Fowler2020) connect the concept with criminological studies. The book provides theoretical and practical insights into understanding how emotional labour is performed by legal actors, such as police, prison officers, lawyers, and voluntary sector practitioners. By engaging with the concept, they suggested that solely offering emotional labour cannot build up the legitimacy of the criminal justice system. While the book pays much attention to how emotional labour is related to public relations, it spares little space to explore the roles of emotional labour in understanding crimes and victimization.
The research on deviance-associated emotional labour is limited to studies within the sex work literature (Hoang, Reference Hoang2010; Pinsky & Levey, Reference Pinsky and Levey2015; Sanders, Reference Sanders2002; Sanders, Reference Sanders2004; Sanders, Reference Sanders2005; Tsang, Reference Tsang2021). Sanders (Reference Sanders2002; Reference Sanders2004; Reference Sanders2005) explored the ways in which British female sex workers utilized emotional labour, such as manipulating humour, to increase their business popularity. Hoang (Reference Hoang2010) found that female sex workers in the low-end sector in Vietnam tend to engage in repressive emotional labour, while those in the mid-end and high-end sectors engage in expressive emotional labour. Other research has shown that sex workers may use multifaceted emotional labour to improve their survival within the sex industry (Kong, Reference Kong2006, p. 409; Pinsky & Levey, Reference Pinsky and Levey2015, p. 438). However, as sex work has been decriminalized in many regions, treating it as deviant or criminal would raise moral concerns. Thus, it is evident that the concept of emotional labour has not been well applied in criminological literature.
In this research, we will demonstrate that emotional labour can provide theoretical and empirical insights into understanding health fraud. From a theoretical perspective, health fraud offenders have to monitor victims’ emotions and control their own emotional expression in order to sustain the emotions desired by their victims. Meanwhile, these offenders often present themselves as employees of health-care or medical companies, indicating a labour feature to their fraudulent activities. Moreover, the ultimate goal of health fraud is to obtain financial gain while posing as a service provider, which aligns with the concept of emotional labour. From an empirical perspective, experimental studies suggest that fraudsters may possess significant abilities in perspective-taking, negative emotion recognition, and self-emotion regulation (Krokoszinski & Hosser, Reference Krokoszinski and Hosser2016, p. 76; Wang et al., Reference Wang, Liu and Bernat2021), indicating their skills in emotional management. Despite these hints niching the connections between emotional labour and health fraud, little is known about how health fraudsters actually perform emotional labour as means of committing crime.
4. Health fraud in China: legal and cultural context
China is one of the most victimized countries for health fraud. The increasing elderly population in the country and the rising demand for health-care products and services, which reached an estimated market value of RMB 2.7 trillion in 2021 (Iimedia Research, 2021), make older adults the primary targets of health fraud. Facing the problem, the Ministry of Public Security (2022) launched a crime-prevention campaign from April to June 2022. It was claimed that RMB 8.4 billion were successfully protected from being lost to health fraud.
Despite recent efforts in law enforcement, the Chinese criminal justice system is hindered by the absence of explicit and specific legal statutes for health fraud. For example, no provisions in the Chinese criminal law pertain to the definitions or characteristics of health fraud. As a result, health fraud, with its varying nature, is often categorized as different crimes by the courts, such as fraud, fundraising fraud, contract fraud, endangering drug safety, illegal business, or production or sale of counterfeit medicine (Jin, Reference Jin2022, p. 56; Su & Qian, Reference Su and Qian2022). These legal gaps add a high level of complexity and difficulty for the criminal justice system in China to investigate, prosecute, and sentence health fraud cases, which not only impedes the ability of the state to crack down on health fraud, but also creates extra obstacles for the victims to access justice.
In addition to legal barriers, health fraud victims also face harsh blaming from society. Phrases such as “You are victimized for being so foolish!” and “There’s no fool like an old fool!” are common in health fraud cases. The victim-blaming culture, which places undue responsibility for victimization on the victim, is not unique to Chinese society. Those who blame the victims can be family members, friends, neighbours, or even the victims themselves. The prevalence of victim-blaming in health fraud may result from a limited understanding of offenders’ manipulation skills and victims’ inherent vulnerabilities (Zhou et al., Reference Zhou, Xu and Wu2023). However, limited attention has been paid in academia to raising awareness of vulnerability manipulation, particularly in health fraud literature. If this gap remains unaddressed, victim-blaming culture may continue to thrive, leading to increased vulnerabilities for elderly victims. Therefore, the current research intends to bridge this gap by incorporating the concept of emotional labour in understanding the manipulation tactics used by health fraud offenders.
5. Research questions, data, and method
The present study aims to understand how Chinese health fraud offenders commit their crimes through the use of emotional labour. Rather than focusing on analyzing offenders’ specific emotional states, the study focuses on examining the overall pattern of emotional labour used by the perpetrators. The core research question guiding the data analysis is: What strategies do health fraudsters employ to perform emotional labour in order to manipulate elderly victims?
All data were collected in China, the most populous nation with the biggest health-care market share. Three data sets were used for qualitative analysis, including semi-structured interviews, judicial documents, and media reports. The first data came from 13 semi-structured interviews with the secondary victims—family members of health fraud victims. Initially, we planned to interview the primary victims of health fraud—the elderly. However, the plan did not go well as most of the approached victims were reluctant to be interviewed, partially due to the high prevalence of victim-blaming culture in Chinese society. Therefore, we changed the interview pool towards secondary victims—the primary victims’ family members or close relatives. Interviewing secondary victims has both advantages and disadvantages. While lacking the voice of the primary victims, interviewing secondary victims may minimize the potential harm to the primary victims and obtain the victimization details that the primary victims may not be willing to share. We adopted three inclusion criteria to ensure the reliability and validity of the interview data: (1) the interviewees should be family members or close relatives of the primary victims; (2) the interviewees should have a fair knowledge of the victimization experiences; (3) the interviewees must be adults. Due to the COVID-19 pandemic, we conducted 11 interviews online and two in person. Each interview lasted between 40 minutes and one hour after informed consent was obtained. The research follows the guideline of research ethics at the University of Macau.
The second data set came from judicial documents of health fraud in China Judgement Online (CJO)—an official online repository that archives all available Chinese judicial records since 2013. Each judicial document details the testimonies of offenders, victims, and witnesses, as well as the material evidence and court judgments. Judicial document analysis has gained widespread acceptance as a valuable and standard research method in recent years (Michelson, Reference Michelson2019, pp. 345–9; Xin & Cai, Reference Xin and Cai2020, pp. 7–8; Zhang & Xia, Reference Zhang and Xia2021, pp. 1478–9). Keywords such as “health-care product fraud” (baojianpin zhapian), “health fraud” (jiankang zhapian), and “elderly frauds” (yanglao zhapian) were used when searching for cases between 2013 and 2020. The cases that did not involve older adult victims were excluded. The research team finally screened a total number of 233 judicial documents. Each document was randomly assigned a code by the year that courts prosecuted. Using NVivo 11, the research team read each case to extract codes, themes, and broader themes for the thematic analysis. Although cases collected from CJO may not be representative of all health fraud against the elderly in China, the richness of the cases nevertheless provided a rare opportunity to examine detailed information about how health fraud was accomplished.
The third data set came from data mining of media reports in Wisers, one of the largest Chinese newspaper databases. Keywords such as “health-care product fraud” (baojianpin zhapian), “health fraud” (jiankang zhapian), and “elderly fraud” (yanglao zhapian) were used to screen the fitted material in the database. In the Wisers database, we identified 194 newspaper articles published between 2009 and 2019. These articles were downloaded and read manually to inform us of relevant victimization experiences.
6. Health fraud offenders in China: the emotional labour of fraud
Health fraudsters cannot overtly disclose their deceptive intention of promoting fraudulent products and services. To conceal deceptive motives, fraudsters need to behave in a manner that older adults perceive as trustworthy. To create and maintain a distorted reality for older adults who share increased anxiety as well as growing needs for emotional closeness and social interactions, health fraudsters adopted emotional labour as a critical trust-building method, attracting and hunting the victims into the scenarios that have been manipulatively fabricated. By performing emotional labour, health fraudsters who win the trust and respect of victims possess more bargaining power in promoting their cheating goods. The following sections explore three types of emotional labour that health fraud offenders utilized to commit the crime: the labour of anxiety relief, the labour of filial piety, and the labour of social networking.
6.1 The labour of anxiety relief
The first type of emotional labour used by offenders was to relieve the anxiety of the elderly. Through this tactic, health fraud offenders target older adults’ anxiety about diseases and fear of death, luring them into health product scams. Our interview data found that not only did older adults with health problems spend much money on fraudulent health products, but those in good health were also attracted by the claims of “preventing cancer,” “preventing cardiovascular diseases,” and “achieving longevity.” Under the pressure of the escalated threat of illnesses, older adults experience escalated anxiety as time goes by. To increase the success rate of fraud, offenders resorted to three specific tactics to perform anxiety-relief labour: impersonating experts, creating fantasies, and using pension baits.
6.1.1 Impersonating experts
First, fraud gangs often impersonate experts to exploit the elderly’s trust in authority (Figure 1). Due to China’s unbalanced medical resource allocations, it is relatively difficult for the elderly to receive diagnoses and treatment from reputational doctors in less-developed cities and rural areas (Chen, Yin, & Xie, Reference Chen, Yin and Xie2014, pp. 2–3). Having the opportunity to be diagnosed by “top experts” could be highly appreciated by older adults. For example, in Case 2019–61, the fraudsters impersonated the head of the China Academy of Traditional Chinese Medicine, the director of the Beijing Bone Disease Research Institute, and the director of the Beijing Bone Disease Treatment Centre. All these titles sounded reputational and prestigious. The fraudsters trumpeted their fabricated identities to catch older adults’ “top experts” mentality and build trust with them. After the trust had been established, fraudsters usually provided so-called “free medical consultations” and cheated that older adults had physical illnesses. Once arousing older adults’ anxiety about their health conditions, they faked the effects of the products and induced the elderly to buy them.
When spoken by an “expert,” the benefits of these health products became convincing for the elderly. Two interviewees said:
My grandfather bought some honey at a high price, which seemed to be called “emperor honey.” The so-called “experts” boasted that it could prevent cancer and various diseases. My grandfather was convinced that this “emperor honey” was beneficial for his health. (Interviewee No. 2)
Those drugs looked pretty common and were also available online at low prices. However, these “experts” took advantage of the prestige they had built among the elderly and claimed they were valuable and worth hundreds of dollars. (Interviewee No. 1)
The record from judicial documents also reflected similar means:
The fraudster Ren admitted that he made up the facts and exaggerated the curative effect of health-care products. These products were described as medicines for various diseases, and the fraudsters claimed that the products were developed by the Ministry of Astronautics Industry and were only given to leaders of the Ministry of Astronautics Industry. They then lied that the products could improve bone mineral density, alleviate cardiovascular and cerebrovascular diseases, protect the liver, and even fight cancer. (Case 2019–70)
Figure 1. The case of fraud in the name of free travel drew great attention from society and was reported on national television.
6.1.2 Creating fantasy
Second, health fraud gangs were used to performing “magic” to convince the elderly regarding the miraculous effects of the fraudulent products. As the saying goes, seeing is believing. Some pseudoscientific tricks can easily win older adults’ trust in the products’ effectiveness. For example, health fraud gangs used a “warm potion” (they were selling) to revive a “dead” fish that was only frozen for several minutes. The trick is shown in a judicial document:
The fraud gang used the so-called “chicken blood experiment” to demonstrate the efficacy of their product. They slaughtered and drained two cups of blood from a chicken. They first secretly added chemicals to one cup to prevent the chicken blood from coagulating, then added their products to that cup. Then they announced to the elderly that chicken blood in that cup did not clot because their product could treat cardiovascular and cerebrovascular diseases by dredging blood vessels. This has led many older people to believe they will have a good heart and blood system by taking their products. (Case 2019–45)
If the above tricks could offer some hope for the elderly, witnessing patients who recover in a short period could be even more appealing to older adults. One interview can shed light on this:
A master on the stage “randomly” selected patients for treatment, and the audience scrambled to raise their hands and shout. A woman who could not walk was carried up to the stage. The master pressed her several times, and she moved excitedly. I knew that woman was a shill, but my mom refused to accept my judgement and always said: “You don’t understand the pain of patients. You don’t know what a master can do …. If only I could stand on the stage!” This was not the first time she had contacted this so-called “magic doctor,” but she hadn’t gotten better in all these years. (Interviewee No. 5)
6.1.3 Pension baits
Third, fraud gangs exploited the elderly’s anxiety about the cost of living in later life and made empty promises of pensions to lure them into scams. They usually launched pension investment programmes, claiming to invest in nursing homes and health-care products, which attracted the elderly to join their “pension scheme.” This tactic has been illustrated in the following two cases:
The fraudster Deng said that his company has a policy benefiting the elderly. As long as the elderly paid 3,600 yuan to buy three kinds of drugs, the company would provide a pension for them. In the first year of payment, the company would give them a pension of 300 yuan per month. As long as the elderly are still alive, the pension would increase by 300 yuan annually until they die. The victims believed Deng’s words that they could secure their retirement by paying 3,600 yuan once. (Case 2016–12)
The defendant Wen pretended to be a deputy manager of a pension base and made empty promises such as buying health-care products to apply for a pension certificate and holding the certificate to visit the pension base. “If you pay 5,000 yuan, you can become a member,” said the victim Chen, “and then you will be issued a blue card to travel to the base, with free accommodation. You can also go there and get a medical check by a specialist.” The victim paid 10,000 yuan for his wife and himself. (Case 2019–37)
With health products, fraud gangs came to the elderly who were worried about their financial capacity to respond to illnesses. Health fraud gangs acted as a saviour to give the elderly who were eager for health a sense of trust and security.
6.2 The labour of filial piety
The second category of emotional labour provided by offenders was in the name of filial piety. Loneliness is a pronounced risk factor among the elderly, especially in China, where rural-to-urban migration has contributed to many empty-nest elderly (He & Ye, Reference He and Ye2014, pp. 354–5). Fraud gangs exploited the elderly’s loneliness for the crime: they pretended to provide filial piety for the elderly to reduce their loneliness. In the news reports, we found much seemingly absurd but heart-breaking news: in 2017, the police in Guangzhou cracked down on a fraud gang. The gang defrauded the elderly into attending free health talks and selling fake drugs and health products at high prices. Some older adults refused to co-operate with the police investigation even after discovering they had been cheated. One of the victims, a 72-year-old man, claimed that his children were all abroad and no one looked after him. Although he knew he had been cheated, the old man felt the “salesman” was closer to him than his children. He refused to report the case to the police (Sohu News, 2017). In another news report, Uncle Chen, the health fraud victim who was aged more than 80, said: “Police officers, could you please not punish him (the fraudster)? He (the fraudster) concerns me more than my son. I view him (the fraudster) as my ‘godson’” (Pengpai News, 2022).
However, Uncle Chen did not know that his “godson” named him in the address book as “slave No. 4.” Fraud gangs exploited the elderly’s desire for social support and relational closeness by approaching those who lived alone. Tactics for performing filial piety labour include ritualized VIPs, regular visits, and exploiting the national rhetoric of aged care.
6.2.1 Ritualized VIPs
First, fraud gangs often made the elderly feel cared for by providing emotional labour similar to those offered by salespeople to VIP guests. They usually approached the elderly by telephone or distributing leaflets and warmly invited them to attend health lectures, where they would serve them tea and water and give them gifts, thereby gaining the elderly’s trust. The fraudster Zhang said:
Older adults don’t have a strong sense of law. As long as we called them and promised to give them free gifts, they would come. Part of the money I cheated was used for the expenses of on-site meetings. Free gifts and fruits were given to these people every time I held the meeting. (Case 2019–05)
In addition to offering complimentary tea, fruits, and gifts, the fraud gangs would limit the number of older adults who attended each meeting to ensure that each senior got enough time to communicate with the salespeople. The fraudster Bu confessed that: “Each meeting is limited to no more than 20 people. After the lecturer explained health products to customers, a group of salespeople would communicate with each customer to promote sales” (Case 2019–12).
Meanwhile, fraudsters would get closer to the older adults by picking up and seeing them off. In the above case, the witness Wang confirmed that:
He went to the meeting as a receptionist, and his wife Yan was responsible for picking up and seeing off customers. He took the customers to the designated hotel, and after the lecture, he sent them home with the gifts he had bought. Cheng also confirmed that he would pick up the elderly by Didi taxiFootnote 1 and take them to the venue at the appointed time. (Case 2019–12)
Likewise, the fraudster Wang confessed that:
The salespeople would bring the older adults to the meeting hall, seat them, and hand out numbered sheets of paper. They would accompany the older adults throughout the lecture. After the “expert” finished the lecture, they took the older adults to consult by serial number. (Case 2018–06)
6.2.2 Regular visits
Second, fraudsters regularly visited older adults who were alone at home, providing the seemingly filial piety to gain their trust. After establishing a good relationship with the elderly in the above meetings, the fraud gangs obtained much information about the elderly, such as their health status, family income, and whether they lived alone. They then screened the information, chose suitable targets, and conducted one-to-one fraud through repeated door-to-door visits. One interviewee demonstrated the experience of an 80-year-old woman living alone:
My next-door neighbour’s grandmother lives alone. When she saw Ganoderma lucidum (a valuable Chinese herb) health products on T.V., she called to place an order, and they were delivered shortly by a “salesman” …. After that, the fraudsters visited her regularly, claiming they had a new health product to treat other body parts and asking if she needed one …. Rarely did anyone talk to the elderly lady. Therefore, as soon as someone visited her, she felt excited and energized. Besides, the fraudster was good at coaxing. Thus, she was taken in. (Interviewee No. 9)
Some health fraud offenders intentionally arranged the visit at a time when only older adults were at home:
The fraudster Hua specifically instructed the salesmen not to mention their intention of selling products to the elderly, but to come to the door when the children at home are away …. The salesmen go to the door when the young people are not at the older adults’ homes, afraid of getting caught. (Case 2017–10)
6.2.3 Exploiting the national rhetoric of aged care
Third, fraudsters exploited the national rhetoric of “caring for senior citizens” to perform seemingly filial piety. They pretended to respond to the national advocacy of “giving back to the elderly” by providing them with free health services. The older generation, who have a higher authority appeal, could be easily defrauded by the cheated rhetoric. After gaining the trust of the elderly, they vigorously promoted their health products. A news report demonstrates this trick explicitly:
The elderly saw the news video of the famous TV station fabricated by the health-care product company in the health-care lecture. The introduction of the health-care product in the video was recognized by many veteran generals. Uncle Xue, who attended the health-preservation lecture: “All of them are in military uniforms. We were even given hats when we went there. We thought it was the army when they gave us yellow hats.” (Sohu News, 2018)
Likewise, in Case 2015–16:
The fraudster Luo and others first presented under the guise of the non-existing “China Caring and Helping the Elderly Association” (CCHEA). The fraudster Wang then rented Tianshui Cultural Palace as their activity site and distributed leaflets in the name of CCHEA. To entice the old to participate in their activities, they used slogans such as “sharing the country’s worries, helping the elderly, and performing filial piety on behalf of their children.” After that, the fraudster Yang introduced Luo to set up the Tianshui branch of CCHEA and worked as a medical and health lecturer dispatched to Tianshui by the association. The headquarter is located in Beijing and has established more than 20 branches in China. (Case 2015–16)
The means of exploiting the national rhetoric could also be employed via phone or online. In Case 2020–45, the victim Li narrated his experience of being cheated out of more than 50,000 yuan:
Li received a phone call at home. The guy on the phone claimed to be the section chief of Baoding Middle-Aged and Elderly Rehabilitation Centre in Hebei Province. He told Li that, in accordance with the spirit of the CCP’s 19th National Congress documents and relevant regulations in Hebei Province, he could enjoy subsidies when purchasing drugs. The fraudster sent products by post and asked the victim to give the money to the courier each time. Li was cheated six times in total. (Case 2020–45)
In sum, health fraudsters often offer hypocritical filial piety for lonely elderly people through three specific strategies: providing attentive service for ritualized VIPs, maintaining close relationships through regular visits, and exploiting the national advocacy of “caring for the aged.” It may result in the situation described above, in which some older adults were unwilling to report fraud to the authorities, even being aware of the fraudulent nature.
6.3 The labour of social networking
The third category of emotional labour performed by offenders was social networking. Loneliness, as a breach of health product fraud, originates from the absence of children’s companionship and the lack of peer communication. Through widening the elderly’s social network, health fraud offenders meet victims’ emotional and social needs, thereby gaining the elderly’s trust and facilitating fraud victimization. Three specific tactics are involved in social networking, including providing free tours, organizing community activities, and encouraging group therapy.
6.3.1 Providing free tours
First, the fraud gangs took advantage of some elderly’s desire for free tours and social interactions by organizing them to visit so-called tourist sites where the fraudsters promote their fraudulent products (Figure 1). A good case shows this pattern as below:
The fraud gang organised free trips for the elderly and took them to the so-called “health base for retired generals.” The fraud gang arranged for staff to impersonate medical personnel and provide the elderly with bogus tests and fabricated test results. All the free travel time of three days and two nights was adopted to deceive the elderly into purchasing health products. (Case 2019–47)
Some older people might be aware of the fraudulent intentions but still showed their willingness to step into the hoax:
Since my parents had to work and I was at school, my grandparents often had nothing to do. Free travel was attractive to them. I once reminded my grandfather to be cautious as there were so many fraud cases, and he said he was aware of this. Nevertheless, he preferred to travel for free with my grandmother because staying at home was boring: “Anyway, I would love to take only 10 yuan to go out!” Despite clearly understanding the trickster’s tactics, he still spent nearly 10,000 yuan on therapeutic equipment that was claimed to alleviate leg pain. (Interviewee No. 10)
6.3.2 Organizing community activities
Second, given the social needs of the elderly, the fraud gangs organized community activities where the elderly and health fraudsters met. On the one hand, the convergence between targets and motivated offenders increased the likelihood of being victimized. On the other hand, in the name of health-care organizations (e.g. President of the Association for the Care of the Elderly), health fraudsters could make the events seemingly legitimate. In Case 2015–09:
The offenders rented houses and turned them into office spaces and activity rooms. They formed chorus and dance teams, which only admitted those who had purchased their products. What’s more, they elected the chairman and vice president of the club to further win the trust of the elderly. (Case 2015–09)
One interviewee also shared the experience that her father frequently visited an unlicensed traditional Chinese medicine (TCM) clinic for acupuncture. She was puzzled by her father’s daily attendance at the TCM clinic. Her father answered: “Even if it is not my turn to get an acupuncture today, having tea and chatting with them is delightful. The doctor is so kind to us. The patients are our relatives and friends.”
These community activities concealed health fraudsters’ deceptive motivations. From older adults’ perspectives, the fraudsters were kind, generous, and open-hearted community workers who organized a wide range of community events from goodwill. From fraudsters’ perspectives, these activities are opportunities to win older adults’ trust and set up the hook. This tactic creates the disparate reality of “community activities” from older adults’ vision, giving rise to the risk of being defrauded.
6.3.3 Encouraging group therapy
Third, fraud gangs offered the opportunity for group therapy and facilitated peer reference among the elderly. People with similar problems often group together, and older adults are no exception. The elderly relieve stress by chatting or complaining about their shared experiences and common illnesses. During group therapy, they also introduced useful drugs to each other. One interviewee complained:
My parents sent me several pictures and asked me how to take a particular drug and what it was for. I checked, and sure enough, there are no qualifications or certifications for this drug. It was even reported that some individuals taking this medicine had kidney illnesses. I asked her where the pictures came from. It turned out that an uncle had been taking this medicine for two years. Hearing that my mother had related diseases, he gave her two vials [Figure 2]…. They had no idea what the medicine was and just believed, “I’m not feeling well and need some health supplies.” (Interviewee No. 3)
Figure 2. Screenshot of the WeChat conversation between the interviewee and her parents. The father was asking for information about the drug, which was recommended by a friend. The interviewee described it as a “Pyramid selling drug.”
In group therapy, health offenders find an ideal tunnel for manipulating the role of word-of-mouth in promoting fraud victimization. In Case 2019–02, the fraudsters revealed their means:
After arriving at the company, the salesman will introduce the products to the customers. When the customers were uncertain about making a purchase, the steerer, a person who pretended to be a patient, would find a topic to discuss with them, telling them that they felt very comfortable after consuming this kind of product and would stick to it for about six months. As a result, the potential customers would believe in the quality of products. If they thought the product was too expensive, the steerer would pretend to purchase a package with them for a discount of 2,200 yuan, then return the fake purchase to the company. (Case 2019–02)
By abusing the elderly’s emotional and social needs, health fraudsters behaved as emotional labourers to manipulate the elderly into making distorted financial decisions. Although some older adults may remain alert initially, they may subtly and incrementally get lost in scenarios full of deception and manipulation tricks.
7. Discussion and conclusion
Emotional labour is common practice for employees’ management of verbal, facial, and behavioural displays (Hochschild, Reference Hochschild2012). Although most literature is situated within management and labour fields (Bono & Vey, Reference Bono, Vey, Hartel, Ashkanasy and Zerbe2005; Hülsheger & Schewe, Reference Hülsheger and Schewe2011; Humphrey, Ashforth, & Diefendorff, Reference Humphrey, Ashforth and Diefendorff2015), the concept shows great potential for understanding health fraud against the elderly. Nesting within three sets of data in China, the country with the largest ageing population, this paper extends the scholarship of vulnerability manipulation by examining how health fraudsters use emotional labour to facilitate older adults’ health fraud victimization.
The present study found that three types of emotional labour (anxiety relief, filial piety, and social networking) with nine specific tactics were adopted by health fraudsters to commit the crime. The tactics for enacting the labour of anxiety relief include impersonating experts, creating fantasies, and using pension baits. The tactics for enacting the labour of filial piety include offering ritualized VIPs, providing regular visits, and exploiting the national rhetoric of elderly health care. The tactics for enacting the labour of social networking include providing free tours, organizing community activities, and encouraging group therapy. Thus, emotional labour plays a vital role in committing health fraud.
This study contributes to the existing literature in several ways. First, the findings reaffirm the perspective of vulnerability manipulation, which emphasizes the significance of recognizing fraudsters’ intentional manipulations of victims’ vulnerabilities when interpreting fraud victimization (Zhou et al., Reference Zhou, Xu and Wu2023). The study presents three forms of emotional labour to demonstrate how health fraud offenders engage in emotional labour to strategically manipulate social interactions with older adults. The findings contribute to the efforts to raise awareness of vulnerability manipulation, which may help mitigate the harm and negative consequences of victim-blaming culture in both China and other countries.
In addition, this study expands the theoretical understanding of emotional labour by demonstrating its relevance in the context of criminology. Previous research on emotional labour has largely focused on the fields of labour and management studies, in which it has been identified as a significant factor affecting employees’ job satisfaction, job performance, and psychological wellbeing. Although emotional labour has been introduced into criminological and social legal studies in recent years, such as in the context of sex work (Hoang, Reference Hoang2010; Sanders, Reference Sanders2002; Sanders, Reference Sanders2004; Sanders, Reference Sanders2005) and criminal justice literature (Phillips et al., Reference Phillips, Westaby and Fowler2020), the application of the concept still remains rather limited. This study shows that emotional labour can be tactically employed by health fraud offenders as a means of manipulating older adults into their scams. The concept provides additional theoretical insights on the nature of health fraud.
Finally, by focusing on the Chinese context, which has the largest group of potential victims, our study sheds light on how fraudsters exploit specific cultural characteristics to advance their goals. The tactics of manipulating submissive personalities (e.g. impersonating experts), appealing to filial piety, and exploiting nationalistic rhetoric demonstrate that fraud can be culturally shaped. This finding highlights the significance of considering culturally embedded vulnerabilities when studying health fraud in a transnational context.
In terms of policy implications, the findings of this study suggest the need for support-based and education-focused approaches. On the one hand, communities need increased efforts to address the emotional and social needs of older adults, such as alleviating anxiety and fear related to end-of-life issues, providing the companionship of children and care, and offering activities to prevent social isolation, which should be a priority. On the other hand, authorities and the criminal justice system should place greater emphasis on educating the public on the identified manipulation tactics, which will not only enhance individuals’ knowledge and skills in recognizing fraudulent schemes, but also promote awareness of vulnerability manipulation in society. In conclusion, instead of blaming older adults for falling into health fraud scams, it is more important to recognize the challenges they face in detecting the manipulation tactics used by fraudsters who use emotional labour as a disguise.
Despite these contributions, several issues could be further addressed. First, only secondary victims were interviewed in this paper. Although interviewing secondary victims allows us to obtain the data that primary victims may not be willing to share, future studies may gain added insights if primary victims could be interviewed. Second, the current study limited its focus only on health fraud. Future research could explore whether the concept of emotional labour could be applied to explain other types of fraud, such as romance fraud, investment fraud, and pyramid schemes, or other types of crime such as bullying or human trafficking, etc.
Acknowledgements
Authors thank Prof. Sida Liu and members of the Criminology Weekly Meeting (犯罪学7日谈) at the Department of Sociology, University of Macau, for their constructive suggestions on earlier drafts of the paper. This research is supported by Multi-Year Research Grant from University of Macau (MYRG2022–00199-FSS).
