Helpless in the face of old diseases
The decline in the grassroots public health system not only meant helplessness in the face of a new epidemic, what was worse, when a once-preventable infectious disease flared up anew, it was difficult to suppress. A perfect example of this is dengue fever.
Dengue fever is popularly known in Taiwan as "Heavenly Dog Fever." It is an acute infectious disease caused by a virus infection transmitted by the Aedes aegypti ( L.) and the Aedes albopictus (Skuse) mosquitoes. Symptoms of the disease are high fever, severe headache, muscle and joint pain, nausea, vomiting and skin eruptions. During fever there can be bleeding from the gums and nose which, if serious, can lead to shock and death.
The earliest record of dengue fever in Taiwan dates from 1870. In 1942 some five million people, representing 83% of the total population of the time, were infected by a dengue epidemic. After a forty-year hiatus, in 1981 dengue fever broke out anew in Liuchiu Rural Township, Pingtung County. About 8000 people were infected, some 80% of the rural township's overall population.
According to the Department of Health's Center for Disease Control, studies have shown that the reason for the outbreak of dengue fever in Liuchiu was that there had been no instances of the disease in 40 years and consequently few people had adequate antibodies against it. So when local fishermen landed on the shores of Southeast Asian countries, contracted the disease and then brought the virus back to Taiwan, it was spread by local carrier mosquitoes, leading to an outbreak that soon got out of control. Making matters worse, health workers had long since lost their sense of fear and had become lax. In the end, this all led to a tragedy where almost the entire township "went under."
Until 1994 dengue fever had only occurred on a large scale in southern Taiwan. The central and northern part of the island had not been threatened. But in 1995 a case suddenly did crop up in Taipei County that drew serious attention from the Department of Health because it suggested that the disease was moving north. As a result, over the last few years as Taiwan enters each summer season, everyone is on full alert.
When dengue fever was attacking southern Taiwan, the average health center in a rural township had only five employees. But communities there are spread widely and it required a great deal of time and personnel to visit each and every community and inspect outdoor containers of standing water, destroy carrier mosquitoes, and spray disinfectant. A doctor from a southern county admits that dengue prevention work had not been very good.
New wine in an old bottle
The fact that a disease previously wiped out is now difficult to control shows the epidemic prevention system does indeed leave a lot to be desired. Where should this work of putting "new wine in an old bottle" begin?
Chen Meei-shia, director of the Department of Public Health at National Cheng Kung University, emphasizes that, compared with today, before 1970, when economic conditions were not as good as they are now, the government was really only able to provide the public health system with meager resources. Despite this, good work was done because the national policy was very clear, as indicated by their motto: "public health [i.e., prevention] is more important than treatment." Thus, public health circles have high expectations resulting from the appointment of Chen Chien-jen as minister of health, since he comes from an epidemiological background and his appointment reversed the usual practice of appointing a minister of health from the treatment sector.
In June, as the SARS epidemic abated somewhat, Taipei City Councilor Hsu Chia-ching organized a symposium on "Community Epidemic Prevention and Public Health" to which she invited the superintendents of Taipei's municipal hospitals as well as grassroots health center personnel to voice their opinions.
"You really have to feel sorry for our nursing staff," says Head Nurse Chen Li-hua of Hoping Hospital. It fell upon her to speak for health care workers at the grassroots. The average district in Taipei City has a population of more than 200,000, but on average there are only seven public health nurses per health center . . . how can they cope? Also, Hoping Hospital originally had more than 400 nurses, yet when the hospital was cutting personnel costs it made certain to first cut the nursing budget so that one third of all nurses became contract hires with no work guarantees. The percentage of those leaving the profession surpassed 60%, and Head Nurse Chen now has no choice but to train a never-ending stream of new personnel. In addition to this, the management of nursing personnel in Taipei is not structurally unified. For example, nurses working in primary and middle schools come under the municipal Bureau of Education, and there is thus a great risk of creating holes in the epidemic prevention system. She proposes putting these nurses under the control of the municipal Bureau of Public Health to prevent a problem from arising.
Weng Lin-chung, superintendent of Taipei Municipal Chung Hsing Hospital, says after infections broke out in several hospitals, the number of outpatients quickly dropped by 50%. Obviously the 50% who did find it necessary to come to the hospital were patients who genuinely needed hospital care. This statistic highlights what is out of balance in Taiwan between the treatment system and the health centers which are charged with prevention. If health center nurses could get those patients who really don't need to visit the hospital to work on changing their diet and on personal hygiene, thus increasing their health consciousness, they wouldn't end up at the hospital in the first place, and the hospitals could concentrate all their efforts on the seriously ill.
Good health, not treatment
DPP Taipei City Councilor Hsu Chia-ching says the health center is the community's first line of defense against epidemics but that it is not tied in with the treatment structure. There is no professional intercourse between personnel. This is a major failing. Second, from the point of view of personnel and budget allocation, the current situation "favors doctors over nurses." The job of taking care of sick patients falls on the shoulders of the nurses yet they are not given adequate personnel resources. Finally, most of the budget goes to the treatment sector to buy equipment, expand hospitals and hire doctors. The recent 50% drop in outpatients at public hospitals shows that if half the outpatient budget were used for prevention the burden on the national budget could be reduced considerably. Hsu hopes Taipei Municipality can take the lead in reform and bring other cities and counties along with it.
Although the all-out "battle against the demon" has revealed a fundamental problem with Taiwan's public health system, this is also an opportunity to turn a crisis into a turning point.
Judged on capital efficiency, we can see the result of an over-reliance on treatment leads to a bottomless pit for expenses and an erosion of the national economy and personal finances. To replace this with something new, we should be thinking along the lines of encouraging good health and preventing disease as a substitute for the traditional diagnosis and treatment approach, because only by investing more capital in public health prevention measures can we lower significantly investment in the treatment sector. This is precisely the spirit behind the phrase "prevention is more important than treatment."