Taiwan Today

Because health care facilities tend to concentrate in urban areas, the isolated and poor residents of mountainous Hualien county long suffered from inadequate care---until Mennonite missionaries set up a mobile clinic and, eventually, one of the island's most respected hospitals.

Hualien in the forties could have been described as the Appalachia of Taiwan. The county, isolated from the rest of the island by the Central Mountain Range, was to a large extent inhabited by impoverished Ami, Atayal, and Bunun indigenous tribes people on the periphery of Taiwan society. Health problems caused by malnutrition and bad sanitation, such as malaria, tuberculosis, and parasitic diseases, were endemic. With the exception of a small government-run health station, established in 1947 to provide basic primary and out-patient care, medical facilities were nonexistent.

Things have changed a lot since then, and patients fare much better. Take, for example, the family of Huang Fei-ting (黃斐婷). Huang, a half-blood Ami, lives in Fengpin, a small rural township south of Hualien city. The town's resident population of around five thousand is 90 percent Ami. In the past year, her 75-year-old father has been hospitalized twice, once for bronchial asthma and a second time for gastrointestinal bleeding. Fengpin has a health station with one general practitioner and a dentist, but no emergency care service. For treatment of serious medical problems, residents must travel forty minutes by bus to a veterans hospital in Fenglin town, or ninety minutes to Hualien city.

There are four major hospitals within the Hualien city limits. Huang's family always goes to the Mennonite Christian Hospital (MCH), a regional hospital and second largest of the four. Why not the others? Huang says it has become a habit. “It's the oldest hospital in this area,” she says. “Most of the people in the township had been coming here long before other hospitals appeared. We have come here since we were little. The foreign doctors and tribal nurses have always been very nice to us, and they would never turn away poor people who could not afford to pay. It's our hospital, so to speak.”

Such reputations are not lightly won. Much effort has gone into the development of the Mennonite Christian Hospital from humble beginnings to its present admirable stature.

In 1948, a mobile clinic sponsored by the overseas relief mission of the Mennonite Church was set up to provide free medical services to the indigenous tribes and the poor people of Taiwan's east coast. The Mennonites, founded by Menno Simons (1492-1559), are a Christian sect that advocates pacifism and the simple life. Unlike the small, stationary government health station, the Mennonite mobile clinic team could provide health care to people in poor remote areas by traveling regularly to the tribal settlements scattered throughout the county's mountainous and nearly inaccessible interior.

In 1954, the Mennonite Church's mission headquarters in Kansas sent Roland Brown to Hualien. Brown was a missionary doctor, and his mission in this case was to expand upon the clinic's work by establishing a hospital. The Mennonite Christian Hospital, as it was named, served as a public medical facility and as a headquarters for the mobile clinic team. Although MCH provided umbrella health care services, the mobile clinic continued to be its primary weapon in the fight against disease. Indeed, before 1979, when Hualien finally had its first government-run mobile medical clinic, MCH was the only local medical establishment providing mobile health care services. The team consisted of a minister, who also served as the driver, and a doctor, pharmacist, and nurse.

From 1970 on, Lin Hsiu-mei (林秀妹), an Ami graduate of Hualien's Mennonite Nursing School, worked in the hospital's public health department. Now the hospital's community health department supervisor, Lin originally served with the mobile clinic. In those days, she says, the team's main task was battling parasitic diseases. "There were hardly any toilet facilities in the isolated settlements," Lin says."Everyone urinated and emptied their bowels in the fields. They didn't wear shoes or sandals. And they didn't practice correct sanitary habits, like washing their hands before eating. Parasitic diseases were epidemic. Children with bloated tummies were everywhere."

The mobile team's work went beyond public health education, health care, and administering anthelmintics to destroy parasitic intestinal worms; they were sometimes barbers, giving haircuts to children afflicted with head lice, and they occasionally oversaw construction of drainage ditches and latrines.

Since its establishment, the hospital has sought to meet the medical needs of the community and to provide health care in those areas neglected by public and private facilities. Patients able to pay for these services did so, while those who could not were covered by the hospital's charity fund. In 1973, MCH became the first facility in Taiwan to initiate a home health care program on the east coast. In the eighties, it pioneered support groups and funds for various categories of patients, including those suffering from leukemia, disabled people confined to wheelchairs, and those receiving dialysis treatments.

By that time, MCH had become an integral part of the local community, having expanded from a basic clinic in the fifties to one of the region's major hospitals, offering patients both Western medicine and Chinese herbal medicine treatments. A long overdue 200-bed facility was opened in 1981, replacing the dilapidated three-decade-old 30-bed hospital building. The staff had grown from the two or three doctors and ten nurses of the early years to an average of over forty, including as many as ten doctors. MCH ended its mountain-area mobile clinic program in 1984, five years after the government started to provide similar services. MCH still maintains two non-mobile extension health care facilities in the remote northern and southern mountains of Hualien county. These provide basic medical services to the indigenous tribes people farthest away from health care.

But the eighties also saw the onset of several problems. Up to the end of the seventies, the Mennonite mission headquarters, MCH's primary sponsor, had funded almost everything, including the construction, operation, and maintenance of the hospital's facilities. In the early eighties it decided to reduce its contributions. Financial aid was cut back until it covered only missionary doctors' salaries, and as more retired, the funding decreased accordingly.

As the eighties drew to a close, MCH was forced to embark on a difficult process of transformation. Money was not the only root cause. Better economic conditions islandwide were resulting in an improvement of health care facilities, and increased availability of medical care on the east coast. MCH was no longer the area's sole provider of quality medical care.

Harold Lue (呂信雄), a Hualien-born hospital management professional, took over in 1986 as administrative vice superintendent. The first financial report he saw showed a NT$2 million (US$75,000) deficit, but Lue was not overly concerned. “The decrease in the church's financial support of the hospital was timely,” he says. “Taiwan's economy had improved greatly and most of our patients were insured. Therefore, our charitable expenses were substantially diminished.”

According to Lue, the hospital only needed minor adjustments to its management policy to ensure a sound financial base. “Facing different social conditions and under great pressure from competition, the hospital needed to change. In addition to rationalizing the personnel structure and simplifying working procedures, I thought we would really need to systemize the charity fund,” he says. “I didn't think that it was right to give charity beyond our ability. Moreover, because more charitable funds were available besides ours, we only had to allocate about 10 percent of our revenue to the hospital's charity fund.”

Now, nearly a decade later, the hospital earmarks NT$300,000 (US$11,000) per month for the promotion of public health through MCH's community health department. The hospital's charity fund separately donates NT$5 to $6 million (US$185,000 to $222,000) annually toward subsidized health care services for needy patients. There are no operating deficits.

The biggest problem stems from the retirement of the missionary doctors. Chou Tiang-hong (周恬弘), director of MCH's public relations department, says that the preparatory period was adequate, but that the mental adjustment hasn't been easy. "They have done a good job here," he says. "People talk about how these Western doctors introduced new concepts and techniques, and about their Christian compassion and good influence on local doctors. With the missionaries around, the local staff always had someone to look up to; when these role models leave, the staff seem to feel sort of lost."

Western missionary medical staff always played key roles in the hospital. Chest surgeon and founder of the hospital Roland Brown served over forty years; project planner for home health care and Alcoholics Anonymous Helen Williams served thirty-seven years; nursing school founder and nursing educator Susan Martens Kehler served over thirty years; gynecologist Alvin Friesen, nicknamed “blood bank” for his frequent blood donations, served eighteen years and married an Ami woman. These four have received the Medical Contribution Award of the Republic of China, initiated in 1990 as a tribute to those who provide medical care in remote areas.

Christopher Leuz of Richmond, Pennsylvania is a plastic surgeon, medical vice superintendent, and the last missionary doctor at MCH. He first came to the hospital in 1978, volunteering for a three-month stint. He returned to serve as a resident doctor from 1982 to 1985, and came back again in 1993. He notices one benefit in particular that Western doctors have brought to the hospital. “In the United States, when doctors present options, they encourage patients to choose the treatment,” he says. “Here in Taiwan, doctors without Western training tend only to tell the patient what treatment must be taken. One reason for the successful doctor-patient relationships at this hospital is that we communicate better with our patients and have thus earned their trust.” Leuz also admires his predecessors' vision in recruiting nurses from among the local indigenous tribes. He regards these nurses as essential to the cultivation of strong doctor-patient relationships and the strengthening of links between hospital and community.

Leuz says that the missionary doctors have done a splendid job. But he adds that, right from the start, the mission's goal was eventually to turn over hospital operations to local people. “One objective for all the missionary doctors here has been to improve public health,” he says. “During the past forty years, hospital care has been keeping up with the ever-rising standard of medicine in this country. But we have also tried to train people who can take our place. Here, the mission's job is mostly done. The hospital has grown up. It would be wrong not to let the hospital's administration make its own decisions and the local people run the hospital.”

But who was qualified, who had the necessary experience to take charge? The problem became acute when Roland Brown retired in 1990. The prolonged three-year process of re-establishing hospital leadership was among the most difficult challenges the hospital ever had to face. In the United States, there is often no overlap between a hospital's administrative staff and its medical personnel. But in Taiwan's closed hospital system, the superintendent must have both administrative and medical capabilities. Brown had searched for the right successor before he retired, to no avail. The hospital's acting superintendent quit after two years, and Brown was summoned back to his old post. He kept searching for the right person but almost gave up hope, concluding that, for Taiwan's doctors, “Hualien was further away than the United States.”

A call for help went out through Christian media channels, in Taiwan and abroad, and at last the call was heard. Taiwan-born neurosurgeon Peter Huang (黃勝雄), a Thomas Jefferson University faculty-member who had practiced medicine in the United States for twenty-five years, decided to return for an interview at MCH. Huang, raised a Presbyterian, had done volunteer work overseas for two months per year since 1983 and he had served at MCH in 1987. When offered the job, he accepted. Huang moved to Hualien at the end of 1993, leaving behind a million-dollar annual income, a four-acre estate, and a comfortable living environment in Philadelphia, to become MCH's superintendent. “Yes, if I had stayed in the States, I wouldn't have had much to worry about,” he muses. “But Taiwan gave me twenty good years and I want to pay that back. I'm really moved by Dr. Brown and all those like him who served Taiwan's people. I'd like to follow in their footsteps.”

His arrival has quieted more than a few hearts. But there was to be no honeymoon period. One of the most urgent tasks awaiting him was the huge responsibility of raising NT$600 million (US$22 million) for the construction of a new medical building.

In his time as superintendent, Brown had insisted on halting donations once the necessary funds for a project had been received. Only when another need arose was it time to start fund-raising again. Huang has adopted a more aggressive approach. "I'm more open-minded in this matter," Huang says. “I welcome anyone who wishes to make a donation, as long as no strings are attached---I don't want the kind of big donor who comes to the hospital in the middle of the night, drunk, and asks for a room to sleep it off. But I will not compromise the charitable spirit of this hospital.”

The hospital's biggest benefactors are a handful of medium-sized enterprises whose donations each stand around the million NT dollar mark. But contributions from small donors form the bulk of the NT$200 million (US$7.5 million) raised so far by the hospital. MCH also took out a low-interest loan from the central government's Department of Health (DOH) for construction of the new building, which, when finished at the end of 1996, will add three hundred beds to the hospital's existing two hundred.

Recruiting staff has also been difficult, but Huang faces the situation realistically. “Around the world, few people are prepared to forego the convenience and better educational options of urban living in favor of somewhere relatively underprivileged,” he says. “Nobody should be criticized for this. I try to recruit people who have a sense of mission, and especially those practitioners who no longer have to worry about their children's education.”

Huang has managed to sign on Chang Kuang-hsiung (張光雄), a Taiwan-born, California-based gynecologist. Three more potential overseas Chinese recruits include a New York-based pediatrician, a physiologist from Tennessee, and a pathologist, also from New York. Furthermore, there has been an influx of internal, psychiatric, and surgical staff from local hospitals. MCH's staff now stands at 460, including 40 resident doctors and 280 nurses.

According to Huang, as MCH's, funding and staffing changed to meet the challenge of the times, so did the focus of the hospital's health care services. Now that the parasitic diseases which once plagued the area have been brought under control, MCH's new emphasis is on prevention and treatment of head injuries, and care of the elderly.

Where once there were few roads, let alone motor vehicles, injuries from traffic accidents have now become a major public health concern. “Motorcyclists between the ages of fifteen and twenty-five have the highest mortality rate, and the major cause of death is head injuries,” Huang explains. “Some of these young people die because of drunk driving, speeding, running red lights, or not wearing a helmet; and sometimes because irresponsible parents let their kids drive motorcycles illegally.” Huang believes that the emphasis should be on prevention and education, rather than cure. The hospital plans to set up a head injury prevention center in order to raise public awareness of the issue.

Huang's logic concerning care of the elderly is similar: Taiwan's population is aging---more than 7 percent of the population is aged sixty-five or over---and statistics indicate that the figure is 9 percent for Hualien county. In response, MCH will now become a center for geriatric health care. “Our focus will be the provision of chronic care and long-term care programs for the elderly,” Huang says. “We've operated a daycare center since 1991. Now we are working on the training of health care providers in geriatrics. Eventually, we hope to set up a retirement home.”

Peter Huang is establishing a widely respected leadership at MCH. His mission involves a heavy burden of responsibility, but he faces it with confidence. The reason is easy to find. “I'd decided long ago to fulfill God's calling at the age of fifty-five,” he says quietly, “and when the time came, the call was from Hualien.”