Table of Contents

1. Introduction
2. Healthcare Systems
3. Mental Health
4. Control of Communicable Diseases
5. Chronic Diseases
6. Environmental Health
7. Conclusion

Introduction

Taiwan is located in the southeast sea of China with a total land area of 36,000 square kilometers (14,000 square miles). According to the household registration, the total population at the end of 1997 was approximately 21,742,815 persons, an increase of 217,382 persons compared with 1987. Through the extensive promotion of health workers at all levels and with the cooperation of the entire population, health programs in Taiwan have made significant progress in the past. Life expectancy, for instance, has been prolonged by around 30 years since 1945 to 71.93 years for male and 77.81 years for female in 1999. In 1947, the crude birth rate, crude death rate, and the corresponding natural increase rate of population in 1997 were 38.31, 18.15, and 20.16 per 1,000 respectively as compared to 15.07, 5.59, and 9.48 per 1,000 in 1997. In 1952, the infant mortality rate was 44.71 per 1,000 live births; it dropped sharply to 6.35 in 1997. The maternal mortality rate went down from 196.56 per 100,000 live births to only 9.20 in the same period.

In the past four decades, the ten leading causes of death have shifted from acute infectious diseases to chronic diseases such as malignant neoplasms, cerebrovascular diseases, and accidents and adverse effects; acute infectious diseases are no longer on the list of the ten leading causes of death. Three of the notifiable diseases, plague, smallpox, and cholera have long been eradicated. No cases of rabies have been reported since 1959; malaria, which at one time was a threat to the lives of many and was also a major deterring factor to the economic development of the nation, was assessed and officially announced eradicated by the World Health Organization in 1965. Other infectious diseases such as diphtheria, pertussis, neo-natal tetanus, poliomyelitis, Japanese encephalitis and tuberculosis have been brought under effective control. The age composition in Taiwan has shown its transformation from triangle shape to a pillar-like shape. This indicates the age structure in Taiwan now is aging especially in certain counties in Taiwan, such as Pong-Hu County. The aging of the population, the changes in disease patterns, the rapid development in tourism, the growth in the number of foreign laborers, and the increasing threat of imported infectious diseases have expanded the scopes of health services and made them more intricate at the same time.

Healthcare Systems

Before 1995, there were 13 different kinds of health insurance scheme under three major systems: the government employee¡¦s insurance system, the laborer's insurance system, and the farmer's health insurance system. The three systems differ in their legal grounds, the administrative authorities, the insurers, the target population, and the payment coverage. A planning committee was set up under the Council for Economic Planning and development in 1988 to draft an overall national health insurance (NHI) plan. Meanwhile, a need to expedite the implementation of the program earlier than planned had been repeatedly expressed by the public, and this is the phenomenon that is opposite to the acceptability of social medicine in the U.S. The NHI program has been implemented since 1995 and the 1997 survey among Taiwanese people on the satisfaction on HHI reached approximately 70%.

Unfortunately, things do not always turn out as we pleased. The NHI has suffered from its financial crisis due to the demand induced by physicians, tremendous waste of the medical resources, etc. Currently, officials of the Department of Health (DOH) are trying to modify the methods of payment and coverage in order to reverse the deficit. They refer to many health care models of developed countries such as U.S., Canada, U.K. and many other EU countries in order to find the best solution to the financial problems of the NHI. They recently introduced the Diagnostic Related Groups (DRG) to curb the medical expenditure, but it is still under debate. In my opinion, the best solution to make the NHI work smoothly and meet the satisfaction among the general public, governmental officials, and healthcare staffs is to bring our social moral into play. This means that physicians should not induced unnecessary demand, patients should not shop for hospitals or doctors, and government should try to modify and forecast the healthcare plan according to the changing of the social behavior.

Mental Health

As a research assistant in the 4-year project of the “Taiwan Schizophrenia Linkage Study”, I have the opportunity to do field research and interview with psychiatric patients (such as schizophrenics), affective disorder patients (such as bipolar, major depression, and dysthymia patients), mood disorder patients (especially PTSD sufferers after the major earthquake in Taiwan last September), and personality disorder patients. The suicide mortality rate in Taiwan in the past four decades exhibited a tri-phasic pattern, with a stable rate in last ten years. In this decade, the suicide rate has grown according to the recent data from the Bureau of Statistics The tenth leading cause of death is suicide in 1997 and it is increasing especially after the 921 earthquake . Methods of completed suicide have not been changing much in these periods with poisoning accounted for 90% of all suicides as compared to the U.S., gun shooting is ranked first . On September 21, 1999, the 921 earthquake with the magnitude of 7.9 on the Richter scale struck the central and northern part of Taiwan killed approximately 2110 victims . This is especially hard for children to recover from the lost of their parents, relatives, and friends. Curing the psychological trauma is not at all an easy mental illness to be treated, it takes time and, of course, requires the treatment provided from mental health services professionals. It is estimated that there will be more and more people suffer from PTSD and the suicide rate will reach its peak at the beginning of April this year. The psychiatric hospital admission rate has also increased these half year after the ruthless earthquake. Medical professionals, psychologists, social workers, public health educators, religious groups, and volunteers all cooperate together to reconstruct Taiwan and make it return to its state before the earthquake as the fastest pace as possible. It is without doubt that the effective and efficient reconstruction and rehabilitation processes during these 6 months is complimented and recognized by the general public and other countries. The economics and stock markets were not greatly affected by this natural disaster. Although Taiwan has been back to its track currently, many people still find it difficult to console their problems psychologically. This is one of the most important public health issues that we need to focus on in this new millenium ¡X mental public health.

From my own observation from the general public, relatives and friends of the mental health disorder patients, and the patients themselves, I discovered that Taiwanese people regard psychiatric hospitals as places where they could feel ashamed of and they would rather die than go and see psychiatrists. Most of the psychological problems could not be cure at once but it is very dangerous for people who do not seek medical treatment since the illness may deteriorate exponentially and may lead to tragedies such as suicide. In order to guide and educate the 921 Earthquake victims to face the rest of their life without suffering from depression or other major psychological illnesses, people in Taiwan should remove stereotypes on traditional psychiatric hospitals or mental health services. Those who have psychological disabilities urgently need the acceptance of the general public, so that they will not be discriminated from the job force or other social settings. Changing our stereotype on mental health patients and let them feel comfortable to seek professional treatments, we definitely can safe thousands of lives.

Annotation:

1. The 921 Earthquake: the major earthquake taken place on September 21, 1999.
2. Source from the lecture of the Community Health Issues course at the University of Utah in Spring 1999
3. China Times press. (September 24, 1999). Special Column on 921 Earthquake. China Times. P. 9

Control of Communicable Diseases

In Taiwan, being in the subtropical zone, the natural conditions are more favorable for the spread of tropical infectious diseases. In 1952 for instance, for a population of about 7.8 million, it was estimated that about 1.2 million were infected with malaria. In 1962 alone, 383 cases of cholera were reported, with 24 deaths. However, through the efforts of all health and medical care institutions in the promotion of control measures, the general improvement of the living standards and environmental sanitation, and the availability of public water supply and other utilities, many communicable diseases have either been eliminated or brought under control. For instance, no cases of plague since 1948, smallpox since 1955 and rabies since 1959 have been reported. In November 1965, the WHO, after careful assessment, officially declared that Taiwan was free of malaria. In the last 35 years, Taiwan has remained free of malaria. Due to people move in and out of Taiwan more frequently for trade and tourism in the recent years, more intensive control measures are thus needed to control the entry of communicable diseases form abroad. The National Quarantine Service of the DOH was established in July 1989 to conduct quarantine and to control the sanitation of ports. Disease surveillance centers under the National Quarantine Service of the DOH are set up in the central southern and eastern parts of Taiwan to collect, investigate, report and analyze data of infectious diseases and to deal with authorities concerned in disease intervention. Immunization is another major prevention strategy to the infectious diseases. Free vaccinations have been made available by the government to infants and preschool age children against communicable diseases such as tuberculosis, diphtheria, pertussis, tenanus, poliomyelitis, measles, hepatitis B, Japanese encephalitis, mumps, and rubella.

Hepatitis Control

Shamefully speaking, around 90% of the population in Taiwan will have been infected with hepatitis B viruses by the time they reach the age of 40 years, and this significant rate is ranked among the top of developed countries. Around 15 to 20% of the total population is estimated to be hepatitis B carriers in Taiwan. They carry with the viruses, sources of infection, and are likely to develop chronic hepatitis, liver cirrhosis and hepatoma. Studies show that about 80% of liver cirrhosis and hepatoma in Taiwan are related to the infection of hepatitis B viruses. The prevalence of hepatitis B in Taiwan is a good example of propagated epidemics.

STD control

On July 1, 1988, both syphilis and gonorrhea were made reportable diseases. Since other STDs are not made reportable yet, their statistics are not readily available. Current control measures include periodic examinations by local health agencies of registered prostitutes and complete treatment of cases thus identified, physical examinations of military draftees, pre-natal examinations for pregnant women, periodic physical examinations for employees of business establishments and food industries; and the promotion of health education programs. For the control of gonorrhea, bacteriologic cultures are now conducted in large cities such as Taipei, Kaohsiung, Keelung, Taichung, tainan, and Hualien for early diagnosis and treatment of patients in an effort to the sources of infection.

AIDS control

AIDS is caused by HIV. There is not yet any known cure for the disease nor vaccines to prevent it. The disease is thus considered the most serious pandemic health problem of the century. In 1985, the DOH established a committee for the prevention and control of AIDS. Major control measures include medical care, laboratory testing, health education, training of professional workers, and research and development. Despite the effort to control AIDS pandemics, the emerging globalization, business and trade, tourism, and prostitution are some of the culprit accounted for the spread of the ¡§millenium plague".

Dengue Fever

Dengue fever is a mosquito-borne virus infection with sharp onset of fever, joint and muscle pains, and rash. Fatality though is less than 1%, it can reach to 15 ~50% if one is infected with two different types of dengue fever successively. A joint dengue fever control center was set up 12 years ago by the Department of EPA to plan programs for the prevention and control of the disease. Action has been taken to carry out disease surveillance, to conduct studies and surveys of vectors, to spray and eliminate sources of infection, to promote health education of the public, to provide medication, medical care and laboratory testing, and to supervise local government to carry out control measures. From 1987 and onwards, each year has dengue-fever reported cases with the most significant outbreaks in 1988, 1991, 1994, 1995, and 1998. It is still one of the major concerns of infectious disease in Taiwan.

Since the climate in Taiwan is not possible to be altered, people in Taiwan must seek other ways to overcome the geographical disadvantage by improving the environments and this task needs the cooperation of all residence in Taiwan. It is predicted that there is a epidemiological cycle that indicates that the major outbreaks would possibly take place every 10 years

Enterovirus epidemic in 1998

Other infectious diseases such as mouth-and-hoof disease (MHD), black foot disease, and Enterovirus disease are some major concerns these two years. the Enterovirus disease which extended from April to August 1998 involved thousands of cases of clinical disease compatible with enterovirus infection (i.e. hand-foot-mouth disease, herpangina and various central nervous syndromes) in all parts of Taiwan. There were 64 reported deaths. Most of the 15 deaths with positive viral isolations incriminate enterovirus type 71, although the majority of deaths have not been studied virologically. Most deaths present a syndrome not described in the literature of enterovirus infection; pulmonary edema, cardiac decompensation, shock, metabolic acidosis and central nervous system disturbances. The precise role of enterovirus type 71 in this epidemic is a basic question that requires researches of epidemiologists and health professionals.

Chronic Diseases

Since 1982, malignant neoplasm (cancer) has been climbed to the top of the ten leading causes of deaths and other illnesses do not have the ability to replace its throne nowadays . Liver cancer in 1999 was the first time to be the top. Before 1999, the top was lung cancer. All forms of cancers are on the increase except two: the stomach cancer and the esophagus cancer. The ten leading causes of deaths are very similar to that of the U.S. The trend of illnesses has shifted from infectious diseases to chronic ones. People now have better sanitation and thus with less infectious agents but the life styles for people nowadays are needed to be focus on. Stressful lifestyles, eating more saturated fat, less exercises, environmental pollutant, genetics and many other risk factors all account for the increase of chronic illnesses among developed countries.

Environmental Health

Polychlorinated Dibenzo-Para-Dioxin-Like Chemicals

Due to the carcinogenicity and the considerable impact on our environment and ecosystems, polychlorinated dibenzo-para-dioxins (Dioxins) and their structurally similar compounds such as polychlorinated dibenzo-para-furans (Furans) and polychlorinated biphenyls (PCBs) have become concerns to public health. The sources, exposure levels in various environmental media and corresponding environmental fates, number of significant episodes, and toxicity of these compounds were extensively reviewed. We concluded that, residual PCBs, further efforts should focus on reducing the harmful effects. However, for dioxins and furans, the challenges are to improve the technology to decrease the production of these impurities within the manufacturing process, and to develop the biotechnology to decompose these persistent compounds.

Water Resources

Because of the topographical, and climatic reasons, the lay of Taiwan is mostly high and steep. The rivers and streams are typically short and shallow, which is very vulnerable to natural water disasters, such as flooding by streams caused by heavy rain and many other reasons. As described above, Taiwanese Government needs to take water resource management and water disaster prevention as a priority. The infrastructure of building dams and reservoirs started before the ¡§Recovery of Taiwan in 1945¡¨. Before 1945, there were about eight reservoirs and dams scattered over Taiwan. Between 1952 and 1956, another 9 reservoirs and dams were built. Nowadays, there are 34 dams and reservoirs in Taiwan with uneven allocation and they provide 90% of the total water uses.

Unfortunately, although there are 34 reservoirs, many of them are so polluted that they degrade, and eventually become useless. This degradation is caused by human activities near the reservoirs, contamination by plant nutrients, oil, pesticides, and toxic chemicals such as lead, mercury, and selenium that can destroy both bottom aquatic life and birds that feed on contaminated water organisms.

Due to the continuous silt build up, many of the damming streams in Taiwan cannot carry water into the reservoirs. Some unworthy livestock farmers feed approximately 100 thousand pigs and ducks right in the water resource area of the ¡§Au-Gong-Dian Reservoir¡¨ in the southern part of Taiwan. Consequently, the Tap Water Company has claimed the ¡§Au-Gong Dian Reservoir¡¨ is not suitable as drinking water. Today, many of the reservoirs are used for irrigation only.

According to the statistics of the EPA in Taiwan in 1993, the ¡§Wu-Shan-Tou Reservoir¡¨, in the central part of Taiwan, ahs the silt build up rate as high as 56.7%. It is said that the total waster holding capacity of 34 reservoirs is decreasing at the rate of 1,460 meters cube per year. The water holding capacity is 23.65% less than the original capacity decades ago. The major rivers that provide southern Taiwan with waster supply are so polluted and contaminated and they put a significant risk of people¡¦s health. Even though water is cleaned by purifying processes and other water treatments, it is still unsafe to drink. Many Taiwanese people buy bottled waster instead to make sure they drink safe waster, but buying bottled water is not a good substitution for people who are not wealthy enough to afford it everyday. The waster pollution is really a great issue and not an easy task to do in a short time.

Drinking water in certain areas in Taiwan especially south east coastal areas has very high concentration in arsenic. Studies show that arsenic has high positive correlation with skin cancer and black foot disease. Black foot disease is still now an endemic in certain areas in Taiwan. Again, unsafe drinking water is to blame. Our goal is to see one day, Taiwanese will be able to drink water straight from the tap as many western countries do.

Air pollution

The understanding of the relationship between location distribution of industries and environmental pollution is a primary phase to search for sustainable development in Taiwan. Since July 1, 1995, the EPA in Taiwan required all vehicles and industrial plants to pay an ¡§air pollution control fee¡¨ (APCF) whenever they purchase fuel oils. Moreover, in the near future, the EPA plans to ask all industrial plants and construction sites to pay APCF according their pollutant emission levels. Some people still question the reasonableness and effectiveness of the APCF. All of these doubts pose obstacles to implement the APCF policy.

The atmosphere of the Kaohsiung city where I live is very much polluted. There are so many factors cause the air pollution, but in Kaohsiung, the industrial waste gas, the waste smoke of the cars and motorcycles, and the tobacco smoke are the main reasons of air pollution. Kaohsiung, a major industrial city, has many factories which make it modernize, but also generate a lot of side effects for the ecosystem. The harmful air gases include many kinds of chemical elements, such as PM10, SO2, NO2, CO, O3, etc. All of them are unfit to be breathed. They could hurt our respiratory system and cause cancers. The government, however, has implement many solutions to improve air pollution, but for government alone to play the role is not sufficient. Residents in Taiwan must make actions together to make the air better to be breathed. On the air pollution issues, it is a global problem. If we do not solve it, all of us will face with unfavorable health situations.

Conclusion

For public health issues, it is not easy to discuss them thoroughly due to its nature of broadness. The issues mentioned in this paper are some of the major concerns in Taiwan nowadays. Many of the infectious diseases have their cycles of epidemics. Epidemics hit populations, run their courses, and die out. They disappear either because of cures, or everyone without immunity dies. In this way, pockets of population have disappeared again and again through history. Diseases come into existence, change, and vanish, and some have always been with us. Most diseases are the result of change in our environment, behavior, or both.

Due to the current ambiguous situation of the cross-strait relations, Taiwan, as a country, is long rejected by many international organizations such as WHO due to mainland China¡¦s continuous repression. In my own opinion, it is really an unbearable fact that all Taiwanese must face. I believe that the right to health is the basic right for human beings, but contradictorily, we cannot participate in any of the WHO Headquarter¡¦s Major Programs. This is really depriving and looking down on the dignity of Taiwanese.

Take enterovirus type 71 epidemic in 1998 for instance, due to we are not a member of the WHO, we have much slower information on the epidemic and with less help by others, and therefore, it claimed 64 innocent lives. China is very possible to continue to treat Taiwan like this for another decade, but the health status of people in Taiwan couldn¡¦t be defeated by mainland. Although lack of international support, Taiwanese must overcome this obstacle and meanwhile, actively promote and cumulative our knowledge in public health from other paradigm countries in the western and eastern world.

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