Written by Hsu Hung Bin, translated by Sam Robbins
When the results from the annual university entry exams are released each year, the media loves to compare results across top high schools to see which are performing the best. The number of students who are accepted medicine at university is a common metric used. To take an example from 2013, one report commented on the fact that “one hundred students” were admitted to study medicine from Taipei’s prestigious Jianguo high school (建中). The commonly used, and already rather old used, phrase of “first comes dessert vendors, then doctors” (in reference to which professions make the most money) still to some extent reflects how common it is for parents in Taiwan to hope their children will become doctors.
As a medical historian, I have often had the opportunity to talk to many medical students over the last few years. I often asked these students who are held in such high regard by society exactly why they chose medicine and not some other profession. Some would confidently and proudly say that they want to become a world-class researcher who will strive to the newest frontiers of human knowledge, all the while creating new medical technology that saves countless individuals. Others were instead looking to meet social expectations of a good and stable life by working in a big hospital and thus be able to seek personal and professional development whilst saving lives.
Occasionally, a student would come to me after class and share with me their struggles deciding whether to switch majors or not. There have been increasing discussion over the last few years about the collapse of the healthcare system and the worsening medical conditions. The phrase “五大皆空” (all the key fields are lacking) has become common, referring to the lack of doctors in internal medicine, surgery, gynaecology, paediatrics and emergency care. There has also been discussion of the net outflow of doctors from Taiwan. All of this brought doubts to the once hopeful students as they began their medical education. I often hear students asking questions like “is the medical system here really going to collapse?” “Do we have to leave Taiwan and start a new life abroad?” “Did I make the right choice for my career”?
The main argument made by doctors and medical institutions is that the issue arises from both a “push,” namely that the environment for doctors has become worse, and a “pull” in that salaries are higher abroad. Many doctors have chosen to move to China or Singapore, where they are culturally and linguistically similar. Doctors who already have significant professional experience are leaving the most frequently. One proposed solution has been to increase doctor salaries. Moreover, recent discussion has focused on turning Taiwan into an “international medical centre” by increasing the number of international patients coming to Taiwan for self-paid optional treatments, as a way to bring the needed extra money into the system. However, even this could be achieved, is it really low salaries that are making doctors decide to move aboard?
The Colonial Era (1895-1945)
If we expand our timeframe a little, we can see that ever since medicine started becoming professionalised and developing rapidly in the late 19th century, doctors have been migrating globally on a large scale. Many who studies medicine in Ireland or Scotland in this period would move to England after graduation or to other parts of the British empire. In fact, over half of Irish doctors moved outside of Ireland to work. Some Scottish doctors even ended up in Qing-dynasty Kaohsiung at the British-run Takao port (打狗海關).
Many Taiwanese doctors of the early 20th century followed the networks of the Japanese empire at it slowly expanded into Manchuria and other regions. At the high point, there were roughly 700 Taiwanese doctors in Japanese-occupied Manchuria, which accounted for a third of all doctors in the territory. In Taiwan, following a concerted effort by Japan, western medicine soon monopolised the entire (regulated) medical field. These doctors, who had both a stable income and a relatively high amount of free time became a new force in Taiwan’s upper society. They were promoters of new ideologies, enthusiastic for new things and were generally respected by society at large. Some have referred to the colonial era as a golden age for Taiwan’s medicine. Doctors became a new professional group with their own history and influence who often weighed in on the significant discussions of the day. (The influence of historical legacy is now becoming visible through Ko Wen-je. It is not often that a mayoral candidate from a non-politics background is so willing to use their own professional experience and outlook so freely in an election).
The medical profession became the top choice for well-educated Taiwanese students during this period. However, because the number of places in local medical schools was limited, many students went to the metropole, or to Manchuria or Korea, for further study. Many of those who studied in Manchuria remained there after graduation. Many learnt about the lack of doctors in Manchuria from family members living there for other reasons, and thus decided to relocate there. For example. The famous dermatologist from Kaohsiung, Lo Hok-gak (羅福嶽) once opened a medical practice in Manchuria. Overall, it was only a minority of doctors who moved to Manchuria, and many returned to Taiwan once war broke out. The highest point of outflow of Taiwanese doctors did not start until after World War II.
The scale and influence of doctor outflow from the 1950s to the 1970s was beyond what one might expect. According to survey data from 1963-1973, around 40% of doctors in Taiwan left the country. The majority of which moved to the United States. The United States was a magnet for talent in a range of specialised fields, especially for citizens of developing countries receiving financial aid from the US, including The Philippines, India, South Korea, and Taiwan. If we can say that doctors had become Taiwan’s earliest professionalised elites and that they enjoyed high social status as early as the colonial era, then what was the reason for this fortunate group to choose to leave home after the war? If we can understand the through process and circumstances of these doctors of an earlier period, perhaps we can have a better understanding of our current predicament.
Hsu Hung Bin 許宏彬 is a historian of medicine from Tainan, a historical city in southern Taiwan. He is currently working on the daily practice and business management of Taiwanese physicians in the early 20th century, and, by doing so, tries to reconstruct the relationship between state, market and profession. Other interests include history of opium and history of allergy and immunology on the island
This article was produced in reference to research done by Greta Jones, John Harley Warner, Shang-jen Li, Junkai Chen, Hsu Hsueh-chi, Jungwon Jin, and Ling-fang Cheng.
This article is part of a special issue on Challenges to Taiwan’s medical system beyond COVID-19.
This piece was originally published in 2014. The second part of this article will be published tomorrow.