醫療無國界

──境內也能援外
:::

2012 / 11月

文‧張瓊方 圖‧林格立


台灣優異的醫療技術一向為人稱道,繼50年前農耕隊不辭辛勞進駐中南美洲、非洲等偏遠國家,提供技術援助後,醫療亦成為我國人道援助國際社會重要的一環。醫療援助不只有遠渡重洋到他鄉服務一種模式,在台灣依然可以盡國際公民義務,對友邦伸出援手。

幾乎全年無休的國內醫療院所,隨時都有世界各國的醫護人員來台取經,以及來自世界各地的病患入境就醫,無國界醫療援助天天在台灣發生……。


29歲、來自太平洋馬紹爾群島的牙技師Joshua Drake Lanki,正在台北馬偕醫院學習做齒模,來台一個多月的他,已會講「謝謝」、「不客氣」等簡單且發音標準的中文。他表示,在馬紹爾少有人會治療蛀牙、製作齒模、架牙橋等技術,當地人牙齒有問題多直接拔除了事,民眾因缺牙造成臉部變形、影響腸胃消化等問題嚴重。

他這趟來台灣預計訓練半年,學成後可望幫助家鄉病患留住牙齒。

另一位來自加勒比海島國聖文森、32歲的心臟內科醫師Najaj Jhuneile Peters,被安排在新北市的署立台北醫院受訓。

才剛到台灣一星期,她的芳心已被台灣濃濃的人情味與美味的牛肉麵擄獲。經由大使館推薦,Najaj來台灣學習心臟診斷及超音波技術;只是,她在聖文森服務的醫院目前尚無心臟超音波設備,她打算歸國後向院方提出申請購買。

估計目前約有來自菲律賓、蒙古、甘比亞、以色列、印度、西藏等地區的17位外籍醫師參與「台灣國際醫療衛生人員訓練」,正在國內各醫院受訓中。

外籍醫師來台取經

署立台北醫院院長林水龍指出,從2002年「台灣國際醫療衛生人員訓練中心」成立迄今,總計已培訓41國、713位醫療衛生人員。

一般來說,歐洲國家醫生對針灸及傳統中醫最有興趣,南美、中東國家醫事人員多來學習公共衛生和全民健保制度,非洲則以學習兒科、婦產科和醫務管理為主。

國合會自2003年開始進行友好國家醫事人員訓練計畫,甄選友邦專科醫師、護理人員、醫療行政管理人員、醫檢師、醫學工程人員來台接受為期2~3個月的訓練。包括署立台北醫院與台大在內,台灣共有23家醫療院所加入「國際衛生醫療合作策略聯盟」,協助培訓友邦醫療相關從業人員。

「醫療服務輸出,可以對外介紹台灣文化,又能鞏固邦誼,」署北醫院院長林水龍指出,就算是非邦交國,在密切的交流下,雙方都有深厚情誼。例如蒙古來台受訓的醫護人員已超過百人,回蒙古後還會定期聚會分享台灣經驗,他們都是當地社會的菁英。

除了經由國合會贊助機票、生活費來台受訓的友邦醫療從業人員外,也有不少外籍醫護人員自費來台灣取經。

醫療品質策進會董事長張珩指出,醫學中心的國際醫療合作計畫,列入醫院評鑑項目,因此各醫院多願意積極配合。

醫界龍頭台大醫院自1992年起便開始協助越南提升醫療技術,先後派醫師前往協助完成首例腎臟移植、骨髓移植、肝臟移植、心臟移植等重大手術;舉辦神經學、心臟醫學、風濕免疫、微創手術等各類型醫學研討會。2010年開始執行的台越NTUH-HOPE計畫,先後支援21名醫師前往河內越德醫院協助診療病人及臨床指導。2009年開始推展與蒙古的交流合作,簽署交流協議,協助訓練蒙古醫師及醫事人員。

長庚醫院在代訓外籍醫師上也不遺餘力。副院長鄭明輝指出,目前就有五十多位來自歐洲、中亞、東南亞各國的外籍醫師在院內培訓中,科別以整形外科、顱顏外科、牙科、心臟內科、婦產科為主。

也是台灣奇蹟

透過派駐友邦醫療團的在地深耕,以及行動醫療團的義診協助;再加上來台受訓醫療從業人員的見證,受惠病人的口耳相傳,台灣先進的醫療技術、優良的醫療品質已在國際間打出名號,在當地無法醫治的重大疾病,或束手無策的疑難雜症,紛紛跨國來台求醫。

2010年4月,駐聖多美普林西比醫療團發現2名7歲燒燙傷兒童有組織黏著現象,若不儘速處理,恐有截肢及生命危險。因當地缺乏燒燙傷醫護人員,外交部立刻協助轉送來台治療,在台北萬芳醫院「燒燙傷中心」進行手術,並訓練隨行來台醫護人員後續的照顧和復健工作。

衛生署國際合作處處長許明暉指出,跨國醫療需大費周章轉介、所費不貲,聖多美普林西比2名燙傷兒童算是特例。

基於人道考量,援助友邦理所當然;然而,品質高、費用相對低廉的台灣醫療,早已吸引許多國際病患自費跨國求醫。

台大醫院從1990年左右就開始有國際病人登門求診,台大醫院院長陳明豐表示,當時多是東南亞華僑回台灣看病。近年,病患更來自世界各地。

根據台大醫院統計,去年求診的國際病人以亞洲及中國大陸人士居多(59%),其次為美洲地區(25%)、歐洲(7.5%)。

2011年10月,1歲6個月大的「畢寶」因膽道閉鎖,從越南胡志明市來台就醫,她的父母原計畫帶畢寶去新加坡做肝臟移植手術,但因手術費用需要近千萬元新台幣而打退堂鼓,後來經親友介紹,到台大醫院做肝臟移植,結果非常成功,費用也僅需新加坡的三分之一。

醫術名聞遐邇的長庚醫院,則是全台灣收治國際病人最多的醫院。

長庚副院長鄭明輝指出,長庚國際門診量一年達幾千例,住院病人將近千例,約占整體營運量的5%。舉凡小兒科臍帶血移植、整形外科(包括:淋巴、乳房顯微重建,唇顎裂,小耳症等)、不孕症治療、內視鏡開刀等,都因技術純熟,聲名遠播。

擔任顯微重建外科教授的鄭明輝,首創以顯微血管手術治療癌症切除後上下肢淋巴水腫問題,2009年他將「帶血性淋巴結移植技術」發表於國際整形外科權威期刊後,便吸引許多人跨國前來求醫。

鄭明輝指出,部分乳癌或子宮頸癌手術會將淋巴結一併切除(淋巴結廓清手術),或是放射線治療造成組織纖維化,導致淋巴液無法藉由淋巴系統回流至血液循環,高蛋白組織液不正常堆積,造成上肢或下肢水腫,影響肢體活動。做「帶血性淋巴結移植」後,隨著皮瓣一起移植過來3、4個淋巴結,即能發揮「抽水馬達」的功效,讓淋巴液得以回流,血液正常循環。

長庚醫院兒童血液腫瘤科醫師江東和,則是臍帶血移植手術的佼佼者。

他表示,長庚血液腫瘤科治療團隊從2003年獲衛生署同意進行人體試驗,開始實施非親屬臍帶血移植、2005年臍帶血移植解除人體實驗限制至今,團隊已完成96例臍帶血移植,寫下以非親屬臍帶血移植治癒許多重度海洋性貧血、白血病、免疫不全症候群、骨質石化症、嚴重再生不良性貧血等病童的輝煌紀錄。其中不乏遠渡重洋、慕名求醫的國際轉診個案。

江東和指出,長庚臍帶血移植的成功率已近9成,每年約有10例來自馬來西亞、中國大陸、印度的個案。「印度病人是醫生來台受訓後回去引介來台就醫,馬來西亞案例則是成功案例在病友團體間口耳相傳的結果。」目前還有3位外籍病人移植完正住院康復中,另有7位在排隊等候移植。

10歲的莊小弟,來自馬來西亞,今年2月首次來台進行臍帶血移植失敗,但他們不氣餒,9月再度來台進行第二次移植,這次相當成功,只待狀況穩定就能出院回家了。媽媽黃曉英興奮地說,兒子終於可以脫離每月輸血、每天打排鐵劑的生活,「感謝江醫師讓我兒子重生!」

這樣的故事,不時在台灣各大醫院發生。

國家地理頻道拍攝的紀錄片《台灣醫療奇蹟》中,一歲的IYA因先天膽道閉鎖,從杜拜來到高雄長庚進行肝臟移植手術;埃及的外科醫師SOLIMEN因手部受傷,失去開刀能力,到林口長庚找魏福全醫師進行手術,將足關節移植到手部。3歲大的MISUKI,罹患重度海洋性貧血,在美國找到適合的臍帶血,從馬來西亞來到林口長庚醫院進行移植。

醫療援外,台灣最佳代言

「無論從世界公民的責任或提高台灣能見度的角度來看,國際醫療援助都是醫療從業人員應該要做的事,」台大醫院院長陳明豐認為,台灣有很多經驗值得與他國分享,如感染控制、重症看護、評鑑經驗、病歷管理等等。

但陳明豐也坦言,「國際醫療這一塊,醫學中心不做不行,做太多又惹來不務正業的批評,得拿捏平衡。」

「台灣優先,」長庚醫院副院長鄭明輝表示,從事國際醫療並不會排擠國內的醫療資源,「更何況,在健保給付的框架下,從事國際醫療更能把好醫生留在台灣!」

台大醫院院長陳明豐也認為,醫療行為受法律限制,也不能做廣告,但國際醫療部分應較具彈性,「醫療援外是一種無形的廣告,讓台灣的高醫療水準舉世皆知。醫療服務輸出,堪稱台灣最佳代言!」

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EN

Medicine without Borders—Providing Foreign Medical Assistance at Home

Chang Chiung-fang /photos courtesy of Jimmy Lin /tr. by Jonathan Barnard

Taiwan has long been held in high esteem for the level of its medicine. After half a century in which ROC agricultural assistance teams have been going to nations in Central and South America, Africa and elsewhere, medicine has become an important part of the international aid provided by the Republic of China. And that assistance is not only being provided on foreign soil: At home in Taiwan, too, the ROC is fully meeting its duties as a member of the international community by extending a helping hand to allied nations.

Throughout the year local hospitals are hosting visiting professionals from around the world who come to Taiwan to learn the latest medical techniques. And every day patients from many different nations are seeking treatment at Taiwanese hospitals in this age of borderless medicine….


Dental technician Joshua Drake Lanki, 29, hails from the Marshall Islands in the northern Pacific. He is currently studying at Taipei’s Mackay Memorial Hospital. He explains that very few people in the Marshall Islands can treat tooth decay, make tooth molds, or build dental bridges. Dental problems are typically handled by pulling teeth. The subsequent lack of teeth leads to facial deformation, digestive tract issues and other serious problems. He’s studying in Taiwan for six months. He will then return home to help his fellow countrymen keep their teeth.

Najaj Jhuneile Peters, 32, from Saint Vincent and the Grenadines in the Caribbean, has been sent to get training at the Taipei Hospital of the Department of Health. On the recommendation of the ROC embassy in St. Vincent, Peters came to Taiwan to study echocardiography (the use of sonograms in making heart diagnoses). Unfortunately, the hospital she works for doesn’t have equipment for heart ultrasounds. She plans on putting in an application to obtain that equipment when she gets back home.

It’s estimated that currently 17 foreign doctors from the Philippines, Mongolia, Gambia, Israel, India, Tibet and elsewhere are now in Taiwan under the Taiwan International Medical Training Program.

A medical pilgrimage

Lin Shoei-loong, superintendent of the Department of Health’s Taipei Hospital, notes that since the Taiwan International Healthcare Training Center (TIHTC) was established in 2002, it has trained 713 medical professionals from 41 nations.

Generally speaking, European doctors are interested in studying acupuncture and traditional Chinese medicine, whereas medical professionals from South America and the Middle East come to focus on public health and universal-health-care-system administration. Africans, on the other hand, mostly study pediatrics, obstetrics, and medical administration.

“The export of medical services offers opportunities to introduce the outside world to Taiwanese culture and to strengthen bonds of friendship,” says Lin. For nations with which the ROC lacks formal diplomatic relations, these kinds of exchanges allow both sides to cultivate and deepen friendships. For instance, Mongolia has already sent more than 100 medical professionals to Taiwan. Even after returning to Mongolia, they still periodically gather to discuss their experiences in Taiwan.

Apart from the medical professionals from allied nations that come to Taiwan with grants from the International Cooperation Development Fund, many others pay their own way.

Chang Hang, president of the Taiwan Joint Commission on Hospital Accreditation, points out that providing training to foreign medical personnel is one of the items in hospital evaluations, so medical centers here are generally eager to be on board.

In 1992 National Taiwan University Hospital, Taiwan’s leading research hospital, began cooperating with Vietnam to raise the level of its medical techniques and technology. NTUH has sent its own doctors to Vietnam to teach local doctors how to perform kidney, liver, heart and bone marrow transplants, as well as other major medical procedures. The hospital has held seminars for Vietnamese doctors on topics such as neurology, cardiology, rheumatism, and minimally invasive surgery. In 2010 the NTUH-HOPE Program between Taiwan and Vietnam was launched. It has provided grants for 21 doctors to visit Hanoi’s Viet Duc Hospital and provide guidance about diagnosis, treatment and clinical practices. In 2009, NTUH began to work with Mongolia, signing exchange agreements and helping to train Mongolian doctors and other medical personnel.

The Chang Gung Memorial Hospital group has likewise spared no effort in training foreign medical personnel. Cheng Ming-huei, a vice superintendent of Chang Gung Memorial in Linkou, points out that there are more than 50 foreign doctors from various European, Central Asian and Southeast Asian nations currently receiving training at the hospital, mostly in plastic surgery, craniofacial surgery, dentistry, cardiology, and obstetrics.

Another Taiwan Miracle

With the deep roots put down by ROC medical teams stationed in foreign nations and the free assistance provided by mobile medical teams, as well as the positive personal experiences of foreign medical personnel who have received training here and foreign patients who have received treatment here, Taiwan is developing a well-earned international reputation for high-quality medical care.

In April of 2010, an ROC medical team in São Tomé and Príncipe learned about two badly burned seven-year-old children with adhesions. If not handled immediately, there was a fear that amputations would be required or the children’s lives would be put at risk. With a lack of burn specialists locally, the Ministry of Foreign Affairs arranged for the children to be brought to Taiwan for treatment. It also arranged for training in aftercare and rehabilitation for medical personnel that came with the children.

Marc Hsu, the director of the Bureau of International Cooperation at the Department of Health, points out that transnational medical treatment is unimaginably expensive, making the steps taken for those two children exceptional.

Based on humanitarian considerations, the ROC provides medical assistance to allied nations as a matter of course, but Taiwanese medicine, due to its high quality and low cost, has also long attracted many foreign patients who pay their own way.

NTUH has treated significant numbers of foreign patients since 1990. Chen Ming-fong, the superintendent of NTUH, explains that early on most of these patients were overseas Chinese from Southeast Asia. In recent years they’ve been coming from all over the world.

Most of the foreigners seeking treatment at the hospital last year were from Asia and mainland China (59%), the Americas (25%) and Europe (7.5%).

In October of 2011, an 18-month-old baby from Ho Chi Minh City in Vietnam suffering from biliary atresia (congenital obstruction of the bile ducts) was brought to Taiwan for treatment. Her parents had originally planned to bring the girl to Singapore for a liver transplant, but gave up on that plan when they learned it would cost the equivalent of nearly 10 million NT dollars. On a friend’s introduction, they went to NTUH for the procedure instead. The operation was extremely successful and it only cost one-third of what it would have cost in Singapore.

The Chang Gung Memorial Hospitals, which are known for their advanced medical care, have treated the most foreign patients.

Cheng Ming-huei of the group’s flagship hospital in Linkou notes that the hospital treats several thousand foreigners as outpatients and nearly 1000 as inpatients each year. These represent about 5% of the hospital’s patients. Linkou CGMH has an excellent international reputation and frequently provides infertility treatments, endoscopic surgery, umbilical cord blood transplants, and plastic surgery (including lymphatic reconstruction, breast reconstruction, and repairs of cleft palate and microtia) to foreign patients.

A professor of plastic and reconstructive surgery, Cheng was the first doctor to use vascularized lymph node transfer to prevent lymphedema after the removal of cancerous lymph nodes. The paper he authored on the topic for Plastic and Reconstructive Surgery, a major international journal, attracted even more foreign patients to seek treatment with him.

Cheng explains that treatment for breast or cervical cancer may require the removal of lymph nodes (lymph node dissection) or radiation treatments that lead to tissue fibrosis. These results may in turn cause blockages that prevent the lymphatic system from returning the interstitial fluid to the thoracic duct and then to the bloodstream, where it is recirculated back to the tissues. Instead, the fluid builds up locally, leading to swelling in the upper or lower limbs that impedes patients’ capacity to move and exercise. With vascularized lymph node transfer, wherein a flap of skin is transplanted along with three or four lymph nodes, the “pumping action” that spurs the circulation of the lymphatic system returns.

Jaing Tang-her, a hematology-oncology specialist in the Pediatric Department at Linkou CGMH, is well known for his expertise with cord blood transplants.

In 2003 the Hematology-Oncology group at CGMH obtained the DOH’s permission to proceed with human trials in carrying out umbilical cord blood transplants between non-relatives. In 2005 the prohibition on human trials for cord blood transplants was lifted, and in the years since the team has performed 96 of these procedures, using non-relative cord blood transplants to treat thalassemia, leukemia, acquired immunodeficiency syndrome, osteopetrosis, and aplastic anemia. Quite a few of these patients were foreigners who were transferred from hospitals overseas.

Jaing points out that CGMH’s rate of success with cord blood transplants is nearing 90%. Every year about 10 patients come from each of Malaysia, mainland China and India. “The Indian patients come on the recommendations of Indian doctors who have come to Taiwan for training,” explains Jaing. “Malaysian patients, on the other hand, are coming via word of mouth from patients who have been successfully treated at the hospital.” Currently, there are three foreign patients at the hospital who have already successfully had the procedure, and another seven who are waiting for transplants.

A 10-year-old boy from Malaysia first came to the hospital in February 2012 for a cord blood transplant. It was unsuccessful, but his family wasn’t discouraged and they came in September for a second transplant. This time it was extremely successful, and he will leave the hospital soon, when his condition fully stabilizes. His mother, overjoyed that her child is leaving behind a life of constant blood transfusions and shots, exclaims, “Dr. Jaing, thank you so much for letting my son be reborn!”

Stories like these play out frequently at Taiwan’s major hospitals.

In the National Geographic Channel’s documentary Taiwan’s Medical Miracle, one-year-old Iya from Dubai, who was suffering from biliary atresia, flew to Kaohsiung CGMH for a liver transplant. Meanwhile, an Egyptian surgeon named Solimen, who lost his ability to operate after losing portions of two fingers to a stray bullet during the Arab Spring, came to Linkou CGMH for microsurgery that reconstructed the fingers with material taken from his feet.

A leader in foreign medical aid

“Whether from the standpoint of meeting global responsibilities or of raising national visibility, the medical community here should be providing international medical assistance,” argues Chen Ming-fong, superintendent of NTUH. Taiwan has a lot of experience worth sharing with other nations, including in areas such as infectious disease control, acute care, assessments, medical records management, and so forth.

But Chen admits that there are potential pitfalls: “Providing international services is something that medical centers ought to be doing, but if you put too much emphasis on it you run the risk of being attacked for not focusing enough on your main mission of meeting the medical needs of Taiwan. You’ve got to strike the right balance.”

“Taiwan is the priority,” says CGMH’s Cheng Ming-huei, who believes that providing international medical services need not diminish domestic medical resources. “In fact, with the payment structure imposed by the National Health Insurance system, the possibility of providing care to foreigners outside of that framework will help to keep good doctors in Taiwan!”

NTUH’s Chen explains that Taiwan’s hospitals are not allowed to advertise their medical services. “Nevertheless, foreign medical assistance is like an intangible form of advertising that informs people about the high level of medical care in Taiwan,” he notes proudly. “Exporting medical services is an ideal representation of Taiwan!”

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