If no one told you, it would be very hard to spot the hospital with Taiwan doctors tucked away next to the Shanghai Power Hospital at the intersection of Jiangsu Road and Yan'an West Road.

In a room on the ninth floor of Chen Xin Hospital lies the eighth-grade son of Mrs. Liu. Two days ago he was running a fever and entered the hospital for observation; Mrs. Liu has been by his side ever since. A chat about health in Shanghai elicits a stream of complaints. Plainly, this is the biggest headache for family members of the Taiwanese who work here.

When Mrs. Liu took her daughter to the local health station for her kindergarten physical, the nurse pulled out a big, old-fashioned needle to take blood. Her daughter broke out in tears and Mrs. Liu herself was quite frightened but nonetheless watched as the huge needle pierced her daughter's tender skin.

Shanghai is full of paradoxes born of its being a city where physical infrastructure is advancing so rapidly that the individual often seems to get left behind. Here, an ordinary urbanite squats with his luggage in front of the train station, a lost expression on his face.

The No. 1 complaint

After much inquiry, Mrs. Liu learned that Chen Xin Hospital had Taiwan doctors, and this made her feel a lot better. Mrs. Liu says life in Shanghai has many pressures but few pleasures. "Leisure activities are hard to come by--but that doesn't matter. What does matter and what the Taiwan business community really needs is their own designated hospital."

"Medical treatment is difficult" is the general complaint of Taiwanese living in Shanghai. Last July the Shanghai Academy of Science conducted a small survey of daily life among a few dozen Taiwanese living in the city. The conclusion: "The biggest complaints of Taiwanese in Shanghai are (1) the low level of culture among Shanghainese, (2) unacceptable quality of medical treatment and (3) security worries about problems caused by people coming into Shanghai from the countryside.

Seeing the medical needs of Taiwanese living in China, four years ago Li Shin Hospital of Taoyuan in Taiwan worked out a cooperative agreement with Shanghai Power Hospital under which they borrowed space and set up Chen Xin Hospital, a dedicated facility to serve Taiwanese. The hospital has a department of family medicine, dental care, rehabilitation and Chinese medicine as well as nine sick rooms for internal medicine.

"Many Taiwanese would rather let things drag on, tough it out, run the risk of letting a disease develop and wait to see a doctor during their vacation back in Taiwan. Their attitude is just to get back home. Money is no object, and the more serious the illness, the more they are intent upon returning because they do not trust mainland medical technology," says Victor Chang, president of Li Shin Hospital, who has been back and forth to China often on medical exchanges. Taiwanese businesspeople are not at all accustomed to the treatment available in Chinese hospitals. China of course does have some first-class hospitals, but generally speaking health care is 15 years behind that in Taiwan.

More than 20,000 Taiwanese have been treated at Chen Xin Hospital in the last four years, with an average of 20 people a day. But, "We are still too small. For example, we do not have an intensive care unit. Serious emergency patients still must be referred to other hospitals," says Chou Ming-jen, deputy director of Chen Xin, who last year was seconded here from Li Shin Hospital in Taoyuan. He even had a patient who had to be referred who told him, "I'd rather die here than be referred to another hospital," a statement that shows how poor an image this patient had of Chinese medical treatment.

To resolve the problem of Taiwanese being unable to obtain satisfactory medical care, Shanghai's Health Bureau and several of the city's hospitals have set up a "green lane" to facilitate access to medical assistance.

Curious labels

But Chen Xin is not a general hospital. What if you come down with a serious illness? Shanghai has a population of close to 17 million, with a land area one-fifth that of Taiwan and 23 times that of Taipei City. This is a huge expanse of territory, and the Taiwanese that live there need to understand the medical environment well.

A year and a half ago Chang Tsui-hua left the secure world of banking and brought along her two daughters to live in Shanghai with her husband. She was psychologically prepared for a medical environment that didn't measure up to Taiwan standards but decided to take things as she found them, saying to herself, "If it's good enough for our mainland brethren, then it's good enough for us."

"Some Taiwanese wives bring over all the medicine they can carry, but isn't this a little too neurotic? Isn't it more dangerous to play doctor?!" This was the way she thought when she first arrived.

But when her 14-year-old daughter had a series of minor medical situations and went a number of times to the hospital for treatment, the experience raised a great many doubts in Chang's mind and led her to understand that there really were vast differences between Chinese and Taiwanese medical treatment.

Perhaps because her daughter couldn't adapt to this change she developed stomach problems. She then went to the Level III, Class A Ruijin Pudong Hospital, the equivalent of a teaching hospital in Taiwan. The doctor gave her a bunch of medicine and when she got home, Chang took a good look at the labels, which were filled with odd-sounding names, and thought she would do some research and find out what they were. "They all seemed to be medicines developed by the hospital itself but our only choice was to take it or not take it," she says.

In addition to the differences in prescribing habits and in the translation of medicinal names, the service mentality of the doctors left quite a bit to be desired. This summer Chang's 17-year-old daughter developed some acne on the side of her lip that bled profusely when the scab broke. This was followed by a blister that continued to grow. Mother and daughter went to Huashan, a teaching hospital known for its dermatology department. The doctor they saw said he would have to excise the blister with a laser. When they got to the laser room the doctor who was to perform the procedure said, "I can't do it. It's too large. What happens if we can't stop the bleeding? Put some salve on it and wait until it gets smaller, then come back." So they took back with them a jar of something that smelled like Chinese medicine, the color of red bean powder, called san-sheng-san. But after using it for a week, it proved totally ineffective.

A week later she returned to the laser room. This time a different doctor was on duty so she carefully repeated what the previous doctor had said and, lo and behold, this new doctor, a woman, angrily responded: "Just because someone else can't do it doesn't mean I can't. But there may be some scarring." Chang Tsui-hua could only console herself with the fact that all popular Taiwan doctors are a bit taken with themselves too. This particular doctor was probably quite capable. And indeed, this was the case. Now the scar has gotten quite faint and the whole episode seems not to have affected in the least the daughter's emotional attitude toward sitting for a university entrance exam.

These experiences with minor problems taught Chang Tsui-hua something: "Mainland doctors are rather brusque and direct. They don't think they are being impolite. It's rather a cultural difference. We'll go again if it's something small, but for something serious, we'll return to Taiwan."

In Suzhou, BenQ employee Jacky Chang married local beauty Zhou Hongan. During a summer vacation, he took his wife back to Taipei for vaccinations, only then discovering that she was pregnant. He is planning to have his wife return to Taipei next year to give birth.

Green lights!

What Chang Tsui-hua says is right. The dermatology department at Huashan, which is affiliated with Fudan University, is truly well known throughout China. It is one of Shanghai's handful of teaching hospitals. Similar hospitals of this Level III, Class A variety number 623 in the country, and 35 of them are located in Shanghai.

Huashan's prominent position can be seen from the huge number of patients it handles. The dermatology department alone sees an average of 3,000 patients a day and has even hit 4,000 in one day. Last year it handled some 720,000 patients and this year expects to top 800,000. Half of those who come from outside of Shanghai are attracted by the department's reputation. The hospital's yearly income runs around RMB1 billion.

Huashan was the first hospital in China to have a cooperative relationship with Harvard University, and very early on understood the medical needs of foreigners residing in the country. As early as 1989 it set up a foreigners' clinic, the majority of patients being from the US, Europe and Japan. The number of patients from outside Shanghai has grown from just a few initially to about 150 a day at present. In recent years Huashan has become one of the hospitals most relied on by the Taiwan business community in Shanghai.

Aside from hospitals like Huashan that have set up special sections for foreigners, the Shanghai Taiwan Affairs Office has worked out an agreement with the Bureau of Public Health to take care of the biggest worry among the Taiwan business community in Shanghai. In October 2001 they took the lead in having the Ruijin Central Hospital in the Minhang District open up a "green lane" for the medical treatment of Taiwanese.

Chu Yu-sheng, deputy secretary of the Minhang District Taiwanese Friendship Association, says that in the past, because many Taiwanese were unfamiliar with medical resources in Shanghai and didn't know where to find a good doctor, they would immediately think about buying a plane ticket back to Taiwan the minute they became seriously ill. But they also worried about what they would do if something happened en route.

The number of designated hospitals for the Taiwan business community in Shanghai has expanded to some 31 district-level institutions in Pudong, Changning, and Xuhui. Taiwanese who come in for treatment are accompanied by special personnel. From registration and examination to paying the bill and getting medicine, the way is cleared with "green lights" all the way.

Many of Shanghai's hospitals combine Chinese and Western medical practices, with the upper floors for Western medicine, and the lower floors for Chinese medicine. Jingkang Health Care Center, which was opened in Shanghai by Taiwan's Federation Clinic, follows this pattern, with expensive diagnostic equipment as well as a section devoted to traditional Chinese medicine.

Keeping pace?

"Green lights all the way" certainly make things convenient, but it's still not enough. In addition to the substandard environment of most district-level hospitals, public hygiene habits are even worse. Patients cough without covering their mouths and they spit and blow their noses out in the street. Whenever you enter a hospital you have to worry about being inundated with germs. In these circumstances, might one not go in with a minor disease and come out with a major one?

Shanghai currently has more than 400 public hospitals and close to 800 joint-venture and cooperative private hospitals and clinics. Taiwanese do not worry that the city is without hospitals but are disheartened that service is not up to standard. The problem with mainland medical treatment is that it's easy to quickly bring "hardware" up to international standards, but can service quality keep pace?

Xu Jianguang, who took over as director of Huashan two years ago, says Huashan put out RMB650 million for a new branch hospital in Pudong that is to be finished by the end of the year. He jokes that he is no longer a doctor but a construction foreman who checks on the daily progress of the work.

"My new office is more stylish than that of the director of Harvard University Hospital or Massachusetts General, but my management standards lag far behind. It's not that I don't have the ability, it's the influence of Chinese institutions, the medical system, the culture. We can't catch up in one big jump, but we'll make gradual progress, and we'll have to do this in conjunction with a rise in the cultural level of the whole population."

"Providing good service to the huge number of patients who visit the Huashan clinic may entail some problems because the fees are so low. If Taiwanese were forced to accept 'basic medical treatment' they would definitely not be happy about it. There has got to be a specific medical service entity or channel for them." Xu Jianguang often urges doctors working in medical centers catering to foreigners to further improve their service mentality.

Shanghai, the Chinese boomtown that is drawing the entire world's attention, attracts more Taiwanese to work or settle than any other city. Although a vibrant place, Shanghai still has its shortcomings. The biggest complaint of Taiwanese there is the flawed health care system. Pictured here is the view from the Bund to the Pudong district.

Lax enforcement

The uneven quality of Chinese doctors has deep historical roots.

During the ten years of the Cultural Revolution, aimed at "smashing the four olds," the proletariat was on top and intellectuals became the "stinking old ninth" (i.e., the ninth category of class enemies). As early as 1958 "barefoot doctors" appeared in the countryside. These were ordinary people with only basic, common-sense medical knowledge. Even now these people are still carrying on their work in some remote areas. Although in the 1990s a great number of doctors returned to China who had been studying abroad, the medical environment in the country was very substandard and many were unwilling to stay.

Associate Professor Richard C. Chien of National Yang Ming University's Institute of Hospital and Health Care Administration has visited medical institutions of all levels on the mainland. Comparing medical education in China and Taiwan, he says that in Taiwan doctors graduate from medical school, do a practicum and training residency in a hospital, then take a license examination. The process of acquiring fundamental knowledge and clinical experience is clear and complete. In China Ministry of Health officials do not strictly enforce the law. Often people who have just graduated from medical school with no clinical experience can hang out their shingles as "doctor in charge."

Chien points out that external medicine places a premium on experience. There are many medical schools in China and many patients. Young doctors can all wield the scalpel and quickly get experience. But when it comes to internal medicine where you rely heavily on sensitive instruments to make a diagnosis, mainland doctors are very far from the mark.

Take organ transplants, for example. The skills of Taiwan doctors in this area are superior but there is a lack of organs. Although first-class liver transplant technique also exists in China, such as at Tianjin Medical University, on the whole the level of skill is uneven. This frequently leads to situations where a Taiwanese patient has had a liver or kidney transplant and, because organ matching was hasty and Chinese doctors have insufficient experience in post-op complications, makes an emergency evacuation back to Taiwan. Many surgeons at National Taiwan University Hospital and Taipei Veterans General Hospital have had some difficult experiences because of failures of transplants done by Chinese doctors.

When one sees a doctor in Shanghai, the medical history handwritten by the doctor can be taken home, as the hospital is not responsible for storing it. The reason for this practice may be that in former times, medical histories had to be given to the person's work unit for safekeeping.

Strange fees

Because Taiwanese are not familiar with the Chinese medical system, stumbling upon a good doctor is a matter of luck. Next to this, Taiwanese also generally complain that it's expensive to see a doctor in China. In a Level III hospital, where Taiwanese more or less accept the level of equipment and service, there is a clinic staffed by specialists and doctors of good reputation but the registration, examination and medicine fees average several times that of the basic clinic.

Since the financial reforms of the 1980s, Chinese government assistance to public hospitals has dropped sharply. Under the pressure of economic self-sufficiency, a chaotic fee structure has emerged, with hospitals creating their own chargeable items, setting their own levels of charges, and suggesting repeat or unnecessary examinations.

Last winter the 83-year-old grandfather of Liu Zongyu, a doctor of Chinese medicine at Chen Xin Hospital, visited Liu's uncle who was working in Kunshan. He neglected a cold, which turned into pneumonia, and was sent to the First People's Hospital of Kunshan. Liu had to enlist the help of a classmate to get him a bed. The following day he went into the intensive care unit and on the fourth day passed away, the doctor explaining this was due to "organ failure." Because the grandfather was elderly, the Liu family was forced to accept the explanation but had to pay RMB10,000 for the four-day hospital stay. "We felt this was actually quite expensive because the doctor really didn't do anything."

Jacky Chang, senior marketing manager in Suzhou for BenQ (IT) Co., Ltd., arrived in 1999. Living among the local inhabitants, Chang married a Jiangsu girl named Zhou Hongan. Three years ago she became pregnant and Chang insisted that while prenatal exams could be done in China, his wife would go to Taiwan for the delivery.

Comparing the medical environments on either side of the strait, Zhou Hongan, who has now traveled more than ten times to Taipei to visit her in-laws, says "It's so much worse in China!" A friend of hers who gave birth in Suzhou arrived at the hospital in the early stages of labor, but the doctors wanted her to wait and come again in the afternoon. A few hours later, the fetus had heart palpitations. Only then did the doctor hurriedly perform a C-section. This total lack of concern for the patient not only unsettled Chang, his wife was so frightened she dared not give birth in China.

Each time her two-year-old son Wei-wei caught a cold and ran a fever, Zhou would take him to a local hospital and the doctor was sure to first give him an anti-inflammatory shot, follow by an IV drip if the fever didn't subside. Once her son received three whole IV pouches. She couldn't stand the fact that her son was in pain and getting so many needles, so she asked the doctor to use a relatively painless infusion needle common in Taiwan. This cost her an extra RMB30. Her son's resistance was poor and she worried that the doctors were giving him too much medicine. Taiwan doctors were always sure to take a gentler approach to treatment and first inform the mother about what they were doing. For Wei-wei to get his vaccines for Japanese encephalitis and German measles on time, Chang Shih-cheng had to request leave to take mother and child back to Taiwan.

Ten years ago Taiwan entrepreneurs and managers were young, strong and single, and there was no great demand for medical services. Ten years later these same men and women have aged and suddenly they realize good health is their most valuable asset in their job. Add to this that now the family lives together, with children and spouses being brought over, it's hard to avoid small health problems. At a time when China's urban development is approaching international standards and when their children's education problem has been solved by the establishment of schools for them, Taiwanese businesspeople are hoping that the health problem can be taken care of, but this basic wish still depends upon the close cooperation of the medical communities on either side of the strait.

Taiwanese are wary of seeking medical assistance in Shanghai hospitals, and for minor ailments they often look for remedies on their own. The three-story Shanghai Pharmacy is stocked with everything they are likely to need--from Chinese and Western medicines to medical supplies.

Getting What You Pay For--Chaos on the Medical Front

The backwardness of the Chinese medical scene is a worry for Taiwan businesspeople and a key topic for the Chinese media. Beijing's Sanlian Life Weekly and China Newsweek both focused on medical reforms this past August and pointed out that for the military and civil service, for workers and for urban employees medical insurance coverage was less than 40%. Fully 79% of all farmers had no insurance whatsoever. There is a huge gap between rich and poor. Poor people frequently complain they cannot afford to see a doctor. In the mid-western region of the country it is estimated that 60% to 80% of all deaths occur at home because people are unable to afford to see a doctor or go into a hospital. The situation is chaotic, with hospitals filing false drug cost figures, taking bribes, and so on, none of which can be stopped despite repeated efforts.

Sanlian Life Weekly cited the example of a nine-year-old boy's appendectomy. The boy's family paid a total medical cost of RMB7,962. Of this amount, RMB3,635 was for Western drugs while the surgeon's fee was RMB304, meaning that the drugs fee was 12 times that for the operation. In other countries the biggest expense is labor, which averages about 50% of the total hospital bill. When the high cost of drugs is shifted onto the patient, how can medical treatment be anything other than expensive?

High prices charged for drugs is no guarantee that they are of good quality. "In the process of going from a developing to a fully developed country it is hard to avoid poor-quality or counterfeit drugs because of the enormous market demand. The patient can be put in a real quandary," says Associate Professor Richard C. Chien of National Yang Ming University's Institute of Hospital and Health Care Administration.

Although recently the Chinese Ministry of Health has begun to investigate hospitals and strictly prohibits doctors from taking kickbacks and bribes, Chien says "He Shen, the infamously corrupt Qing Dynasty official, invented the taking of antiques and other valuable presents as bribes. There are a million ways in China to get bribed." For example, if hospitals require pharmacies to put into a foreign bank account the difference between the price they actually pay for their drugs and the price they report to the government, how can the Ministry of Health find out?

Of course, the taking of bribes by Chinese doctors doesn't have much of a negative influence on the quality of medical treatment, and can even lead to better care for the patient. It's just that if patients want special care, they have to pay a special price. But because Taiwanese businesspeople enjoy a unique status they are preyed upon by the hospitals, and the probability of being seen as a "fat sheep" ready for the slaughter is higher than average. One cannot be too careful. (Teng Sue-feng/tr. by Anthony W. Sariti)

Whether or not someone is ill, he is put on an IV drip. Many hospitals in Shanghai have an "infusion room" where people are seated and administered IVs. The photograph shows Minhang District's Central Hospital.

Huashan Hospital has a century-long history. The elegant Harvard Building was where American doctors saw patients in the past. It now houses a conference center and academic research facilities.

Chang Tsui-hua, who moved to Shanghai 18 months ago, took her daughter to see a doctor and was given several packets of medicine. Perhaps because of the way the medicines' names are translated, she is confused about what ingredients they contain.

The dermatology department at Shanghai's Huashan Hospital is famous throughout China. Patients from outside Shanghai account for more than half of all patients seen.