AmCham arrow Publications arrow Topics Archive arrow Topics Archive 2003 arrow Vol.33- No.8 arrow Cover Story: In the Wake of the Health Crisis
Cover Story: In the Wake of the Health Crisis PDF Print E-mail

This spring's confrontation with the mysterious new SARS virus brought sudden and unprecedented challenges to Taiwan's healthcare system. Controversy is continuing...

 

By Tim Culpan with Lin Mei-chun


This spring's confrontation with the mysterious new SARS virus brought sudden and unprecedented challenges to Taiwan's healthcare system. Controversy is continuing over how well government decision-makers, hospital administrators, medical professionals, the media, and the public at large rose to that challenge. Since SARS may be back, the debate is far from academic.

When the citizens of Taiwan woke up on April 24, they could not have known the horrible spectacle they would be watching that night on the TV news. SARS was among us, that much was known. But it so far seemed under control. Cases numbered less than two dozen, and there had been no deaths. A handful of apparent cases that had turned up in one hospital was raising eyebrows, but the threat was generally played down.

In a briefing to the foreign diplomatic, business, and media community early that afternoon, officials seemed cautious but confident. "We have reason to believe SARS in Taiwan is under control," said the head of the Department of Health (DOH), Twu Shiing-jer. At this stage, Taiwan's suffering had been mostly economic. Air travel in the region was down, while analysts and economists scrambled to put together theories on what impact the epidemic would have on the economy and specific companies. The analysis mostly centered on China, as that was both the source and largest victim of SARS, and a crucial base for much of Taiwan's manufacturing. "The range of the impact depends on the scale of a company's China operations and its location and sales into China," wrote Deutsche Bank in a report titled "Impact of SARS on the Tech Food Chain."

But when the people of Taiwan turned on the TV that night, they were no longer looking at China or Hong Kong. They were looking at Taiwan -- and specifically at the desperate faces of doctors, patients, and nurses pressed against the glass at Municipal Taipei Hoping Hospital. More than 1,000 people were locked inside the hospital for the following two weeks as part of the government's attempts to limit the spread of the disease.

Loss of Innocence

Shutting them in was the government's attempt to ensure that SARS would not spread beyond the walls of that hospital. It was partially successful, but it was the end of Taiwan's SARS innocence. Within days, the first death was recorded, from a different source of infection. A Taichung man had became the first of 83 that would eventually succumb out of 700 officially recorded cases.

It was from that point on that the best and worst of Taiwan's healthcare, culture, and politics were brought out. Within a week, Vietnam was removed from the World Health Organization's list of infected areas on the same day that Taipei's Jen-chi Hospital suffered an outbreak of SARS. Taiwan could no longer brag about its handling of SARS and instead was forced to start looking inward.

Examples of both selfishness and heroism could be found in abundance. Some venal businessmen hoarded supplies of masks waiting for the price to rise, a small number of doctors and nurses fled from their duties, and some people broke quarantine. But most healthcare workers in frontline hospitals bravely ignored their own risk to place patients' welfare first, while most citizens donned facemasks and anxiously went on with their daily lives.

After a period of denial followed by finger pointing, the government got down to business. In mid-May, Twu was replaced by National Science Council Vice-chairman Chen Chien-jen. Former health chief Lee Ming-liang had already been called back to head a special SARS taskforce made up of representatives from all relevant government departments.

Taking Health Seriously

A noted epidemiologist, Chen took over when the crisis was in full swing. On his first day in office, he was dispatched to Geneva to attend a WHO meeting to try to plead Taiwan's case for observer status -- a move that some criticized as an attempt to reap political gains from the crisis but others defended as a worthwhile effort to bring crucial international health information to Taiwan.  

Since taking office, Chen found that the crisis has brought the health portfolio far more importance and credibility than ever before. "Now we're not just getting support, but actually getting a push to do public health reform," Chen told TOPICS in a recent interview.

As one of the chief architects of long-standing efforts to revamp the public health system, Lee Ming-liang agreed that SARS should provide the impetus to complete what he never managed to finish during his term as health minister. "The whole epidemic really showed us a lot of the weaknesses in the system," Lee noted. A foot-high preliminary report on the table in Lee's temporary office at the DOH is testament to the volume of such weaknesses that were discovered and the recommendations devised to remedy them so that Taiwan may learn from the experience.

In discussions with a dozen academics, policymakers, and health practitioners, TOPICS has gathered just some of the ideas now coming forth about what went wrong and what should be changed. For those who were involved in the crisis, looking back on the turbulent months this spring is not merely an academic exercise to ensure that the event is properly recorded. Winter will soon be approaching, and officials fear that SARS will be back again. "Although the chain of transmission of SARS appears to be broken, we can't let down our guard, as more cases may resurface somewhere in the world," said former DOH chief Twu. "SARS has taught us that a single case is capable of igniting an outbreak."

Calls for Reform

While much has been learned about the disease, dealing with it remains as challenging as ever. From a clinical perspective, the first complication is SARS's extraordinary similarity to common influenza. Considering the high number of flu cases each year, Chen says isolating everyone with SARS-like symptoms could impose an immense burden on the healthcare system. Over-reporting of "SARS" cases could wind up being as disastrous as under-reporting, given the necessarily limited number of isolation beds.

That fact makes it even more imperative to change the way Taiwan's medical treatment is structured. A major problem, says Lee, is the lack of a "gatekeeper in our health system" -- a role played in other societies by private clinics or family doctors, who conduct initial examinations and refer patients to specialists or major hospitals as needed. In Taiwan, Lee notes, "anybody can go to any doctor at any hospital at any time -- you don't even need to make a telephone call [to set up an appointment]."  

The system pleases the hospitals, which get paid by the National Health Insurance (NHI) program per patient visit and are keen to see as many patients as quickly as possible. But this concentration of humanity in the big medical centers -- and the habit of Taiwanese to engage in "doctor-shopping," getting not just a second opinion but a third and fourth --- undoubtedly played a part in spreading some of the infections.

The absence of gatekeepers also led to excessive pressure on the hospital system as patients rushed to the most-respected hospitals to see the best experts. "When SARS hit, we needed some of those experts to isolate the SARS area, and some of them to treat SARS cases, but they were all jammed up at the hospital seeing patients," said Lee. To help prevent this situation from re-arising, the DOH is seeking to encourage greater use of consultations at community health centers and general practitioners' offices by increasing the amount of NHI reimbursement.

Educating the citizenry is also an integral part of the reform. Traditionally many patients are reluctant to disclose the details of their medical history when seeing a physician. "The health behavior of the public has to change," said Lee. "They have to realize that when they go to see the doctor, they need to be honest and cooperative." While not advocating curbs on the freedom to switch doctors, officials like Lee are hoping they can at least get patients to stick with the one doctor for a period of time.

Media and Education

To get the word out about health education, DOH knows it needs the media's assistance. But despite countless hours spent trying to let reporters understand the intricacies of the SARS outbreak, health officials continue to be frustrated by the misinformation that got published. "Somebody's got to tell the media to restrain themselves," said Lee. "A lot of things were distorted and skewed."

Among the noteworthy examples was a report by the China Times that a SARS-infected doctor had died -- a day before he actually passed away -- and a claim by the United Daily News that people had been infected through the water supply in a building in Wenhua district.

To make it easier to educate the public and to institute necessary changes in the health system down the road, the government has chipped in with massive funds. The DOH this year will receive a special SARS budget of NT$23 billion (US$670 million) on top of its regular annual budget of NT$35 billion (about US$1 billion). A restructuring now underway within the department is also paving the way for it to be upgraded to full ministry status, which would require legislative approval. When that's done, the organization will have more resources at its disposal to take on both everyday health needs and new threats such as SARS.
 
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