"No matter where you travel in the world, when you say Taiwan has the right to join and the ability to contribute to the WHO, nobody ever disagrees." This is the common experience of many doctors, scholars, and officials from Taiwan. But the fact remains that Taiwan has not been a member of the WHO for over 30 years now.

Why is it that the WHO, which emphasizes pursuing human health across all racial, religious, economic, and social boundaries, is unable to bring Taiwan within its international network?

Here's the way it is.

When the ROC withdrew from the United Nations in 1972, it was also forced out of the World Health Organization, which is part of the UN administrative network. After lobbying by medical professionals in Taiwan, in 1997 the Ministry of Foreign Affairs delivered a formal letter to the director-general of the WHO urging him to invite Taiwan to participate in the WHO with "observer" status. The WHO rejected the request, stating that it would require a resolution of the UN and WHO assemblies, which would be too controversial.

Beginning the following year, and every year since then, Taiwan has asked allied countries to propose to the World Health Assembly (WHA), the body with ultimate authority over the WHO, that it pass a resolution inviting Taiwan to become an observer at the WHO. But this idea is each year opposed by the People's Republic of China (PRC) and a majority of WHA members, because of their "one China" policies. Thus all proposals to admit Taiwan to the WHO over the past few years have been blocked from even getting on the WHA agenda.

The WHO is a specialized agency established by the UN in 1945, which brought together three previously existing international organizations dealing with public health, emergency relief, and the like. With the coming into force of the organization's constitution in 1948, the WHO, headquartered in Geneva, was formally up and running. Once a year there is a meeting of the World Health Assembly and its Executive Committee convenes twice annually. There are six regional committees and offices.

The purpose of the WHO is defined as helping people in the entire world to enjoy the highest possible standard of health. Its main responsibilities are to offer leadership and coordination on matters related to international health, to provide technical assistance, and to promote measures to prevent epidemics, regional diseases, and other illnesses. In addition, the environment, women's issues, food safety, and global pharmaceuticals standards also fall within the purview of the WHO. Member states not only have the duty to provide help to the WHO when asked, but also to directly provide technical assistance and advice to other countries.

Taiwan has had great successes in public health programs that have penetrated even to the countryside. Many other countries think they can learn much from Taiwan's experience in resisting the spread of communicable diseases like tuberculosis and hepatitis B. (photo by Vincent Chang)

Infectious world

"In this age in which there are no boundaries to disease, is it possible that germs circle the globe, but only stop when they get to Taiwan?" asks Lee Chun-jean, a professor emeritus of surgery at National Taiwan University Hospital who is highly respected in the international medical community. As world president of the International College of Surgeons, an organization with branches in over 130 countries, he is often invited to give testimony and advice to committees of the World Health Organization. But he can only pass on Taiwan's desire to join the WHO at private meetings with friends in his role as "a doctor from Taiwan."

"If we were included in the WHO epidemic disease alert network, then we would be notified of any emergency situation anywhere in the world," says Huang Song-lih, a professor in the Institute of Environmental Health Sciences at Yang Ming University. Taiwan is now isolated, and therefore is not notified of important developments, leaving the country to pick up epidemic information only via friendly officials from other countries or from nongovernmental channels. Just look at some of the epidemics that have broken out in recent years: the E. coli 0157 infection in Japan in 1996; avian flu in Hong Kong the year after that, followed by enterovirus that swept through Taiwan itself; the appearance of nipah virus in Malaysia; and the discovery in New York of cases of West Nile fever, previously unknown in the Western hemisphere.... Given the pace of globalization today, "From the point of view of disease control, it is urgent that we join the WHO," opines Huang.

The risk of not having a place in the global disease warning network is reflected in Resolution 107 passed by the WHO Executive Board in 2001, which reads in part: "The need for international cooperation on epidemic alert and response is greater today than ever before due to increased population movements, growth in international trade and biological products, changes in methods of food processing, and social and environmental changes."

In a ranking of the quality of health care in advanced industrial and newly industrialized countries produced by The Economist magazine, Taiwan finished second, behind only Sweden. (photo by Vincent Chang)

Left out of world trends

Because Taiwan is not in the WHO it also cannot participate in discussions of global health policy and is excluded from world health trends, problems that cause many scholars to worry that development of public health policy in Taiwan might be thereby inhibited. Chang Chueh, an associate professor in the Institute of Health Administration and Management at National Taiwan University, is a case in point. As a member of the World Federation for Mental Health and a feminist scholar, she often attends meetings or seminars at the UN, so she feels very acutely the urgency of internationalizing public health in Taiwan. She has for many years not only actively followed the workings of the UN and joined in some cooperative programs, she has also called on various of Taiwan's other NGOs-whether they are working on behalf of labor, human rights, AIDS victims, indigenous peoples, or other projects-to devote more attention to interaction with international NGOs.

"The WHO is by no means the only organization under the UN. Many others, such as the International Labor Organization, the United Nations Development Fund for Women, and UNICEF (the United Nations Children's Fund), are connected to health issues as well. We should be concerned about and participate at all levels," argues Chang. For the past ten years or so, Taiwan has spent so much of its energy and time focusing on the implementation of national health insurance that it has overlooked creating a comprehensive national public health policy. She hopes that Taiwan's health-related NGOs will embrace a more international perspective from which to assess Taiwan's own direction, and assist and monitor the government in taking needed steps.

As a result of her exhortations, over the past couple of years, five or six NGOs have visited the UN to participate in or observe activities held by UN intergovernmental and nongovernmental committees.

"By participating in the WHO we can understand our own issues better," Chang Chueh suggests. She says that Taiwan is still well behind international standards in concepts and actions related to public health. She points to women's health, her area of expertise, as an example. Most countries now recognize that women's health has been neglected for too long, but for many years, Taiwan has only focussed on the health of pregnant women and women who have recently given birth and their infants. Even things like pap smears and breast exams, which have been promoted in recent years, are just following what other countries do, while there is a lack of a systematic exploration of the health and medical policies that Taiwanese women really need. "Doing public health policy, you can't just stay in the ivory tower," she proclaims. Young scholars in particular should interact more with the outside world, so when they look back at Taiwan they will be better able to examine the needs of their own country.

While trying to get into the WHO, Taiwan should at the same time be thinking about what it can learn and how it can contribute to international health issues, such as AIDS. (courtesy of the Center for Disease Control of the Department of Health)

International responsibilities

The internationalization of health policy development does not only mean learning from foreign examples and applying these to domestic needs. In this era of the global village, Taiwan also feels the responsibility to give something back to international society, to share its resources with others around the world who need them.

With economic development and improvement in the standard of living,Taiwan has made clear advances in medical care. Taiwan has had considerable success against many diseases that are subjects of international concern, such as malaria, tuberculosis, AIDS, smoking-related respiratory illnesses, and hepatitis B. Malaria was eradicated here in the 1960s, and there is a system in place for the prevention of TB in which nurses from the public health system personally deliver medications to the homes of TB patients. Moreover, because of its own needs and semitropical location, Taiwan has achieved considerable results in the research and production of pharmaceuticals and vaccines for treating diseases in tropical zones, products which are "orphaned" by major international pharmaceuticals manufacturers because the markets are too small.

In fact, in recent years experts from Taiwan have often been invited abroad to share the "Taiwan experience" in the field of public health. For example, they have been consulted by Uzbekistan with regard to prevention of hepatitis B, and have offered advice to Sao Tome and Principe on its malaria prevention program.

In terms of clinical treatment, not only does Taiwan have quite high standards for both general practice and specializations, "Taiwan has had great successes with critical care medicine, endoscopic surgery, open-heart surgery, and organ transplants," says Lee Chun-jean. Nearly 20,000 open-heart procedures, and 500 successful heart transplants have been performed at National Taiwan University Hospital alone, a quite outstanding record.

From another point of view, the fact that medical professionals from Taiwan want to fulfill their international responsibilities but have no channel by which to do so means that they feel compelled to take every suitable opportunity to try to win WHO membership for Taiwan. Ho Mei-hsiang, an expert in viruses at the Academia Sinica, has had an especially unforgettable experience in this regard.

In 1994, following the collapse of the Soviet Union, Central Asian countries like Uzbekistan and Turkmenistan, were left in dire economic straits and faced a shortage of vaccines for children. The WHO regional committee for Europe made an appeal for funds to the international community. Ho Mei-hsiang, based on a personal friendship with a WHO official, began to raise funds in Taiwan to help out, and with the active assistance of then-Department of Health director Chang Po-ya, US$200,000 was raised in three days. But, because of objections from the PRC and problems over the name under which the money would be donated, the money could not be delivered. And there is no doubt that the money was needed, because a few months later, Ho saw an article in Time magazine in which the head of UNICEF, Jim Grant, appealed to the entire world to donate funds for vaccines for the nations of Central Asia.

"I was really shocked by the whole affair," she says. An organization should help people solve problems, so why did it in this case become an obstacle? Later she told her friend at the WHO about her anger, and her friend advised: Then why doesn't Taiwan try to get into the WHO? This experience stimulated her to contact friends in the local medical community after she got back to Taiwan and actively lobby the Ministry of Foreign Affairs to try to get Taiwan back into the WHO.

Starting with cooperation

Of course, it is not necessary to always go through international organizations to join in global health affairs. Currently many NGOs in Taiwan, such as the Tzu Chi Foundation, the Noordhoff Craniofacial Foundation, and the Taiwan Root Medical Peace Corps, are, for humanitarian reasons, quietly providing many services in developing countries. But there is something else that can be done that is of even more benefit to international public health, and which Taiwan currently rarely undertakes, and that is participation in multilateral public health projects.

Because such projects require a long-term commitment of resources to such activities as education, if they are undertaken through international organizations, then Taiwan's domestic medical successes could be brought to bear even more widely abroad.

Two years ago, a group of medical professionals organized the Taiwan International Medical Alliance (TIMA) in hopes of doing more in this respect. "While public health in Taiwan is pretty well run, the field of international public health involves cooperation with international organizations and coordinated use of NGO and government resources, so it is a different field altogether, one in which Taiwan seriously lacks specialists," says Yang Ming University professor Huang Song-lih, who is also TIMA secretary-general. He has initiated a program in international public health at Yang Ming specifically to train specialists in designing and implementing international public health projects.

Drumming up support

Besides public health scholars, many doctors are also using their influence in their professional communities to get out the word on Taiwan's situation. In recent years, as a result of their outstanding professional and leadership abilities, many medical professionals from Taiwan have been given important positions in various international professional organizations.

Lee Chun-jean, as world president of the International College of Surgeons, was able to take a team of government and NGO reps to observe the WHO regional annual meeting. He has in recent years also been invited by the WHO to take part in discussions on the Framework Convention on Tobacco Control. For two of these years he asked a professor of economics from Chung Hsing University to attend on his behalf under the title of senior consultant to the International College of Surgeons. "We should use every opportunity for experts from various fields in Taiwan to participate in the WHO to raise visibility and show that Taiwan has the capability to help international organizations," says Lee. Though Taiwan has been continually thwarted in its efforts to join the WHO, it must still seize opportunities to interact with the international community, so that when the time is right it will be able to get on track with the world smoothly.

Last May, the Western Pacific Regional Congress of the Medical Women's International Association (MWIA), organized by Lee Kei-yee, president of the Chinese Medical Women's Association, was held in Taiwan. The director of the organization was so impressed that she announced at the closing ceremony that their group would, in its status as an NGO recognized by the UN, support Taiwan's entry into the WHO. And after returning home, she took the initiative to permit Lee Kei-yee to represent the MWIA at the annual meeting of the WHO Regional Committee for the Western Pacific. In addition, Marshal Hsi, a neurologist at Chang Gung Memorial Hospital, and currently serving as vice president of the International Bureau for Epilepsy, has actively called for the use of the power of NGOs to influence governments.

"It is very important to get the support of the medical community in other countries, because doctors can influence politics, and may even become political leaders themselves and become a vote on our behalf," says Wu Yung-tung, the president of the Taiwan Medical Association. Not only does he call on the 30,000 doctors in Taiwan who are in his group to take an interest in the WHO issue, he mobilizes groups representing medical professionals at the county and city level to go to Geneva to lobby and raise Taiwan's profile. And he also uses his wide personal contacts in the medical communities of Japan and Korea to lobby those governments.

Virtue is never lonely

The efforts of Taiwanese doctors and scholars have won a great deal of support from many in the international medical community. Numerous organizations, including the World Medical Association, the International Pediatric Association, the Congreso Mundial de Medicos Tradicionales, and the Medical Women's International Association, have passed resolutions supporting Taiwan's bid to become a WHO observer. Last year more than 100 professors at the Harvard School of Public Health signed a joint letter to WHO director-general Gro Harlem Bruntland, herself an alumna of the school, encouraging her to support Taiwan's entry into the WHO with observer status and adopt necessary measures to lobby WHO member states to also support this move.

The contacts of the medical community have gradually extended to reach into political circles in various countries. The European Parliament, the Central American Parliament, the legislatures of Belgium and several European countries, and the US Congress have all passed resolutions supporting Taiwan. Even more encouraging to Taiwan's medical community is the public support voiced last May by the secretary of the US Department of Health and Human Services, Tommy G. Thompson. At an address delivered to a luncheon meeting of the World Medical Association, he stated that promoting world health is a task that should transcend political boundaries, and while the US is aware that Taiwan's entry into the WHO is a controversial issue, the US will not shrink from taking a public position on the matter.

In terms of the international press, last May the Washington Times called on the US government to "take the lead in ending thirty years of foolishness." Important media outlets in various European countries have added their support from different perspectives. Japan's Sankei Shimbun, noting that two million people travel between Taiwan and Japan each year, editorialized that if there was an epidemic, but notification was delayed because of the fact that Taiwan is not a WHO member, then the consequences could be serious. It concluded: "We hope that Prime Minister Koizumi Junichiro will transcend the opportunistic nature of the Ministry of Foreign Affairs and make the decision to support Taiwan's entry into the WHO."

Sincerity is the key

Looking back at last year, although Taiwan had gathered a great deal of moral support internationally, it still could not change the reality of being unable to get into the WHO. In continuing to seek WHO membership, is there any stone that has been left unturned?

"Have we really, genuinely done anything to help international society?" asks Lee Chun-jean. The WHO has many ideals that remain unrealized, and even the larger countries have not truly implemented them. So does Taiwan really have the desire and will to offer resources and capabilities to the international community?

For several years now Huang Song-lih has had the chance to visit medical organizations, parliamentarians, and public health departments in several countries. His experience is that the private sector can do little more than take the first steps and clarify the issues. After that governments have to follow up or produce some plans for cooperation. For example, once a German elected official asked him whether Taiwan would be interested in joining a tuberculosis prevention plan in Eastern Europe. But because official medical aid from Taiwan currently goes only to countries with which it has formal diplomatic relations, they could not promise anything. "Something like this, that would require a million US dollars, of course needs government participation. But there is still no consensus between the administration and the legislature over the overall direction of foreign medical cooperation and assistance, and the budget allocation is still below UN target levels," says Huang. The government will have to give more thought to the question of how Taiwan should take part in international health and medical affairs.

Meanwhile, other medical professionals often wonder: How can government and NGOs cooperate to participate in international health programs? Is there a need for reassessment or change in how government medical teams provide aid overseas? How can NGOs be encouraged to participate in international affairs? These are areas that require consideration and improvement as Taiwan continues to seek WHO entry.

"We should see WHO entry as a learning and growing process for Taiwan, and an opportunity to fulfill our international responsibilities." Many informed observers expect that if goals of self-interest can be played down, Taiwan can win even more genuine respect from the international community.