Wealth vs. Health
Taiwan's economic miracle has not only brought the nation luxury and conveniences, it has also brought with it a more hectic lifestyle and all the chronic health problems plaguing the West.
By Mat Matich
There are some things money just cannot buy. And there are some things money brings that were not necessarily bargained for. No one doubts that one of the biggest areas of improvement for Taiwan citizens during the past three decades has been in health. Vastly improved medical facilities plus drastic increases in personal wealth have all but done away with many of the illnesses plaguing the island a generation ago. But medical professionals across the island say Taiwan's prosperity has bought first world healthcare paired with first world health problems. Taiwan is now wrestling with the same health concerns as other advanced nations in North America and Europe - lifestyle- and stress-related ailments such as cancer, heart disease, and stroke - while weaning itself off its medical habits of yesteryear. The island is also breeding strains of deadlier diseases as doctors and patients abuse and misuse antibiotics, helping bacteria to develop resistance to the medications we rely on. In this issue, TOPICS gives Taiwan's health, and healthcare system, a checkup to discover what is ailing us, and what new bugs could be making us sick in the future.
- Profiting from the Pain
- Medical professionals describe how the private sector can ease the aches and pains of Taiwan's healthcare system.
- Recommended Daily Allowance
- How Taiwan's healthy appetite for dietary supplements is being hindered by over-regulation.
Taiwan's problem is stress. Domestic politics seem just one notch above an elementary school food fight at times. The stock market is a rollercoaster without seatbelts, and the thought of Beijing looking over our shoulder with sneering conquest-lust is enough to turn anyone gray. The stress in Taiwan is worse than most people realize, insists Tung-liang Chiang, a professor at National Taiwan University's Institute of Health Policy and Management. It is making us sick, he says. "We have to look at this in a new way," Chiang says. "Social tension isn't just a social problem, it is also a health problem. If the society around you is tense and unhealthy, your health will deteriorate." Chiang's theory in a nutshell is this: Taiwan's seemingly overnight modernization has brought wholesale changes in Taiwan's lifestyle, politics, economic life, and social dynamics. Every one of these areas of change is bringing more stress to the island's residents. Citing his own research into the links between rapid social change, stress, and health, Chiang points to a growing gap between the richest fifth of Taiwan's population and the poorest fifth. When the gap is smaller, the rates of chronic disease drop. When the gap between the richest and poorest widens, chronic diseases become more prevalent. Why? Social tension, Chiang says. He argues that the gap in income indicates a rougher economic climate. This in turn produces more stress for Taiwan residents, which pushes them into the arms of a hectic, less healthy lifestyle. Worse yet, he shows that increased tension is compounded in uncertain economic or political times by a corresponding jump in auto accidents and crime, which stems from the social tension in the first place. While not everyone in Taiwan's medical community would completely agree with Chiang's theory on social tension, doctors do agree that Taiwan's full-throttle dash from a third world society to technological and economic powerhouse has given the island more than just wealth. Forty years ago, infectious diseases were the big killers in Taiwan. They struck, for the most part, quickly and cruelly. Pneumonia alone killed more than 10,000 people in 1952, according to DOH statistics. Now Taiwan's leading killers tend to be nagging, chronic diseases born not from viruses or bacteria but from lifestyle or simply old age. Taiwan is now facing first world health problems, but with distinctive local twists. The island is seeing more and more of the same diseases and conditions that affect industrialized Western countries, such as cancer and obesity-related problems. For instance, studies show slightly overweight Asian people to be more likely to develop obesity-related ailments than Caucasians of even heftier proportions. And this is just one of the emerging health trends that are forcing many to wonder just how fit Taiwan really is. Living Large
Almost 50 years ago in Taiwan, if you were lucky enough to survive birth (the infant mortality rate stood at 84.1 deaths per 1,000 live births), you had a high chance of eventually contracting an infectious disease. Taiwan's leading killers in 1956 were pretty nasty. Gastritis and other stomach infections led the pack, followed by pneumonia and tuberculosis (see charts on page 20). Such diseases were one of the reasons that the average life span was just 53 years for men, and 57 years for women in the early 1950s. The good news is that, thanks to antibiotics, improved public sanitation and thorough vaccination programs, Taiwan has all but conquered many of the deadly, infectious diseases that once plagued the island. The bad news is that gastritis, pneumonia, and tuberculosis have been replaced with equally deadly ailments that are much more difficult to prevent and treat. Taiwan's medical community is unanimous in its diagnosis that changes in the island's lifestyle have drastically altered the nation's health and now pose the gravest threat. Cancer, stroke, and heart disease were the top three causes of death in 1998. In 1999, cancer remained Taiwan's leading cause of death, but stroke and heart disease slipped down a notch as accidents emerged as the island's second leading killer. All three conditions are chronic conditions and stem from long-term lifestyle patterns. "We're now facing the same health problems you find in the United States," says Dr. H. Sung Kuo, director of the Bureau of Health Planning at the National Department of Health. Kuo's predecessors had to tackle the daunting task of eliminating the infectious diseases that had pestered the island for centuries. Taiwan's newfound wealth, and the medical technology it bought, did the job well. Now Kuo's job is to save Taiwan from itself -- or more precisely from its own appetite and hectic schedule. "Most of our problems now have to do with lifestyle shifts," agrees Dr. Chien-jen Chen, dean of National Taiwan University's College of Public Health. "Now children in Taiwan receive 15 vaccinations in their first year and infectious disease isn't the problem. Now people get sick and they stay sick with chronic conditions like cancer, heart disease." Most of Taiwan's population lives a very urban lifestyle, even if they do not live in one of the island's larger cities. Their jobs require less hard labor and more time at a desk or counter. And this, as much as diet, is the reason Taiwanese people are suffering from more and more chronic diseases, particularly heart disease, says Pan Wen-harn, a researcher at Academia Sinica's Biomedical Institute. "Even though the pace of our lives is faster, our activity level is much lower," Pan says. "We are spending a lot more time behind a desk." Pan has been studying Taiwan's weight gain problem and the havoc it has wreaked on the nation's health for nearly a decade. Conventional wisdom holds that many of Taiwan's health problems stem from the introduction of a more Westernized diet, with plenty of French fries and milkshakes for everyone. Actually, though, Pan says Taiwanese are not taking in more calories than they did 20 years ago. "I don't blame Western food * it's not that easy," Pan says. "It's more that we have to change the way we look at all food. We have to make sure we get a good nutritional balance." Obesity, as a medical term, is defined as weighing more than one's skeletal and muscular structure can handle without harming one's health. As one piece of evidence supporting Pan's belief: obesity and obesity-related diseases are more prevalent in the rural areas than in Taiwan's urban areas, where Western food is more widely available. Taiwan's heaviest people are found on the east coast or among the indigenous groups, who largely live in the mountainous central part of the island. While the introduction of fast food has not helped Taiwan adopt a healthier diet, Pan contends that it is not hamburgers so much as higher incomes that are ruining the Taiwanese diet. Taiwan can afford to eat better than ever before, but "better" does not mean healthier. With more money to spend, many Taiwanese opt for heavy meat dishes or richer selections, believing these to be more nutritious than plain rice and vegetables. Unfortunately, the opposite is usually true, says Pan. Combine a too-rich diet with a more sedentary lifestyle and obesity is all but inevitable. Obesity is the underlying cause of many of Taiwan's most prevalent health problems, ranging from heart disease to diabetes, and studies show that overweight Asians are significantly more likely to contract such health problems than overweight Caucasians. "Obesity is becoming more of a problem. Although it isn't as bad here as in the United States, in a way it's a bigger problem here because obesity affects Chinese people much more," says Pan. Addressing this phenomenon, a debate is now raging in the international medical community on how obesity should even be defined for Asians, Pan says. Many argue that Asian people should be considered overweight with a much lower body-fat ratio than Caucasians. Pan also stresses that looks can be deceiving, explaining that many Taiwanese are technically obese and do not even realize it because obesity is more a matter of body-fat ratio than mere weight. Chen Chien-jen of NTU's College of Public Health agrees, adding that other historical factors may also explain why Asian people, and particularly Chinese, do not carry weight well. "Chinese people are more likely to have stroke and heart disease now," Chen says. "A lot of people [in the medical community] think this is because our bodies, in the past, survived on very little and became conditioned to that. Now we cannot handle it. We are being over-nourished." But Chen and other medical experts say that while the rise of weight-related chronic conditions is troubling, many such conditions hit the elderly hardest of all. As Taiwan's population grows older, assuming a larger percentage of the overall population, these chronic diseases will become more prevalent. Made-in-Taiwan Health Hazards
The story of how Taiwan's health environment has followed a path from third-world to first-world health problems is not the whole tale. The island also exhibits several unique health problems that cannot simply be linked to richer diet and longer life span. Taiwan's second-most common cause of death, after cancer, is accidents, mainly auto accidents. Car accidents are not an unusual problem, yet they rank especially high in Taiwan among causes of fatalities. In 1999, accidents jumped from fourth to second place in the list of Taiwan's top ten causes of death, due in large part to the inclusion of 9-21 earthquake fatalities. But there was also a jump in the number of auto accidents, depressing officials at the DOH who thought that the nation's helmet and seatbelt laws, and tighter enforcement of the traffic laws, had finally done the trick. In a way they had. The number of overall deaths caused by traffic accidents had fallen. Tougher safety laws helped to steadily reduce the number of deaths from auto accidents islandwide from 12,922 in 1996 to 11,297 in 1997, and 10,973 in 1998. Yet, statistically, auto accident-related deaths have not fallen off as sharply as other causes of fatalities in Taiwan. Why are motor vehicle accidents such a high killer in Taiwan? Once again, the fast pace of life in Taiwan, combined with the high usage of fast-moving scooters, are the main answers that DOH officials and medics can give. Most accident fatalities are the result of trauma to the head during scooter or motorcycle accidents, according to officials. Another esoteric health hazard in Taiwan is the high rate of lung cancer among Taiwanese women. Lung cancer is the single highest cause of death among local women, though less than 15 percent of the nation's women smoke. Second-hand smoke is not the only, or even the primary, culprit. Dr. Chen Chien-jen of NTU explains that the cancer is often triggered by hours spent stir-frying over a smoking wok, a case of domestic duties proving deadly. The clash between traditional duties and modern demands is also plain when tracking the nation's suicide rate. Suicide has continually ranked among the island's top 10 causes of death as Taiwan has modernized, and now rates as the number 10 killer. Chiang Tung-liang of NTU points to this as another sign that Taiwan's transition to a more modern society is creating far too much stress. One prevalent example: many people suffer in trying to balance the pressures of work with traditional Chinese family responsibilities. "People are being torn by the demands of society," Chiang says. It is a bigger problem than that, counters H. Sung Kuo of the DOH. He contends that Taiwan society has not made a great enough effort to help people meet the new demands faced. He cites a lack of adequate social services and especially stresses the need for better patient support in the healthcare system. "We have really failed in this area," he says. Sickness in the System
A quick look at the underlying reasons for Taiwan's high suicide rate shows that, for many, the pressure of modern urban living is too much to bear. On an international level, Taiwan's suicide rate (10.36 per 100,000) is not particularly high * it rates 18.8 per 100,000 in Japan, 7.1 in Britain, and 11.4 in the United States * but the rate swings dramatically. The suicide rate dipped in the mid-1970s, to 8.75 per 100,000 in 1977, rose to nearly U.S. levels in the early 1980s, dipped in the early 1990s, and has risen steadily since the mid-1990s. If suicide can be considered a health hazard, tracking these swings lends support to Dr. Chiang's findings on the relationship between stress and poor health. In addition to the effects of economic trends and political developments, researchers say Taiwan society has also changed in ways that leave people isolated from traditional social and family support networks. Life in Taiwan's big cities, with the consuming demands of the office and loneliness found in large crowds, is pushing many people into depression, especially when they fail to live up to still strong expectations based on traditional Chinese values, says Chen Chien-jen of NTU. Many of the medical professionals interviewed criticized Taiwan's healthcare system for exacerbating the problem of a lack of support for the island's needy or weak. H. Sung Kuo of the DOH insists that Taiwan's healthcare system has also failed to give many patients the support they need. The single largest problem facing Taiwan's healthcare system is a growing gap between doctors and their patients, a gap that stems partially from the structure of the system and partially from Taiwan's medical culture. "Doctors need to do a better job of listening to their patients," Kuo says. "There is a cultural gap between doctors and patients. The doctors write out their diagnosis in English and don't take time to explain anything to their patients. Most of our doctors probably don't even know how to explain common medical procedures in Mandarin." In fact, local doctors generally schedule the smallest possible amount of time to spend with individual patients. Under Taiwan's National Bureau of Health Insurance reimbursement program, doctors are paid a certain amount for each patient visit. This has led to a clear emphasis on quantity over quality, Kuo says, in which doctors try to see as many patients as possible. "Many doctors see more than a hundred people in one morning," Kuo says. In the United States, patient visits average about 15 minutes; in Taiwan, the average patient visit lasts 3 minutes. Kuo says Taiwan doctors tend to diagnose patients quickly, prescribe large amounts of medication and then ask the patient to return for a follow-up visit. It is a system of healing that Dr. Sheng-mou Hou, associate dean of academic affairs at National Taiwan University's College of Medicine and chairman of the department of orthopedics, agrees is focused too tightly on profits. In teaching the next generation of doctors, Hou says his staff is trying to inject more Hippocrates and less Adam Smith. "One of the problems is that everyone wants to be a specialist because they'll earn more money," says Hou. "But I try to teach my students that before you can be a good specialist you have to be a good doctor. And before you can be a good doctor you have to be a good person. You have to care about people."
NTU's College of Medicine now focuses on training physicians to listen to patients more closely and to explain all aspects of the patient's health thoroughly. More importantly, Hou says doctors in Taiwan must understand that a patient's health rests on more than isolated ailments. "If an elderly man is depressed because he is all alone and falls and breaks his hip, you can't just treat his broken hip and send him back on the street," says Hou. "He'll be back. We have to treat all of the patient." Cultural Healing
Modesty can kill and when modesty is a bedrock of cultural values, it can be a serial killer. In 1999, cancer was the leading cause of death among women in Taiwan and of the types of cancer found on the island, cervical cancer rated fifth. In the West, cervical cancer death rates are just a fraction of what is seen in Taiwan and doctors say this is almost entirely due the lack of early detection.
"This is an area where we really need to make improvement," says H. Sung Kuo of the DOH. Cervical cancer is one of the DOH's pressing concerns because while relatively treatable, cervical cancer must be detected early for successful treatment. The exam is not complex but does require a physician, and many women in Taiwan, particular older women, are uncomfortable allowing a male, or even female, doctor to conduct such an examination. "This is especially true with elderly women," says Chen Chien-jen of NTU. "They will not let a doctor examine them, but they are precisely the ones most at risk."
Physicians say this aversion to cervical cancer exams highlights that Taiwan is still in a transitional period in which people are only beginning to change their thinking concerning healthcare. In many people's eyes, medicine is still considered a mysterious matter, says H. Sung Kuo. Most patients do not know what the medication prescribed to them actually does, but they expect their physician to provide them with large quantities of medicines. In other words, prescriptions are treated as near mystical potions expected by patients to relieve all that ails them. And if a physician will not prescribe plenty of medication, patients will shop for another who prescribes with a heavy hand.
"There is definitely a gap between patients' understanding of medicine and the level of healthcare provided," Kuo says. This practice is especially dangerous given that over-prescription is both draining Taiwan's socialized National Health Insurance Program and fostering the development of bacteria that are immune to developed antibiotics (see page 31).
Still Kicking Taiwan is full of medical success stories, though few have actually ended yet. Taiwan's fight against Hepatitis B, for instance, has seen what many hope to be its last battle. By 1984, all locally born infants were being vaccinated and less than 1 percent of all Taiwanese children suffer the disease now. The next battle is to assist the 3 million island residents still carrying Hepatitis B, many of whom are easy prey for deadly liver ailments, the sixth largest killer in 1999.
Happily, other diseases have been virtually wiped from the DOH's statistics. Few people die of such stomach illnesses as gastritis anymore and tuberculosis is seldom seen in Taiwan. Malaria is gone from Taiwan and goiters (a glandular condition that causes the lymph nodes to swell to huge proportions) are now just a memory thanks to the iodization of Taiwan's salt. Another once dreaded sickness, blackfoot disease (which attacks the feet like gangrene) was leveled all but a death blow after authorities discovered that arsenic in western Taiwan ground wells was the cause of the disease.
And while Taiwan has lately found itself hosting a few deadly viruses, such as dengue fever, enterovirus, and the recently encountered hanta virus, the number of virus-related deaths has been very limited. In fact, Taiwan's life expectancy is now on par with that of the United States (see chart).
The necessary consequence of achieving a first-world economy and environment is, of course, developing first-world health risks. The challenge will be for Taiwan to upgrade its medical system to offer first-world healthcare, including addressing patient education and improving patient services and support. If Taiwan is to succeed in defeating today's leading causes of death it will take more than vaccinations and clean plates. It will require changes in Taiwan's lifestyle, the way its people view healthcare and the way doctors view patients. Perhaps the only sure cure for the nation's ailments is time.