Written by Hsu Hung Bin, translated by Sam Robbins
The Post-war years (1940s-1970s)
The hope of higher salaries was not the primary reason that leads doctors in Colonial Taiwan to leave the country. Personal connections, historical circumstances and development opportunities abroad were the decisive factors. “Development” in this instance is not the same as income; rather, it includes opportunities to get involved in research and to enter into the civil service. Similarly, higher salaries were not the main reason doctors left Taiwan for the US in the post-war era. In a way different from what is common now, those leaving for Taiwan in the post-war era were mostly recent graduates and not those with significant professional experience. These students did not receive a scholarship to go to the US for further study. Along with students from other developing countries, they went to the US because its medical system was lacking personal, and they found jobs at the lowest ranks of hospitals across the country. The salary for such medical interns was not high, and the workloads were heavy, especially because the hospitals which provided the best education and treated interns the best were already filled with US students. Taiwanese doctors mostly ended up in large and not very nice public or charity hospitals. In one letter written by an NTU graduate in the US to younger medical students in Taiwan, the graduate writes that most American hospitals “are fully trying to trick stupid foreigners into becoming high-skilled but poorly paid labourers.”
If it were this bad, then why did Taiwanese doctors keep going to the US? Some would jokingly say they were jumping on the bandwagon, as one doctor wrote: “before coming to America, I didn’t really think about whether to go or not, up to now I still don’t dare to say whether it was really the right decision or not.” Still, others were much clearer that they went for career advancement opportunities. In other words, America was able to provide medical professionals with more opportunities for training and development. These young doctors had received an American-style medical education. They had seen how American financial assistance to Taiwan had provided new medical equipment and resources to their teachers and schools. Furthermore, they received an opportunity to go to the US to study. In the eyes of this generation “America” and “medical science” were practically synonyms. The career dream of medical school graduates was to be able to do clinical work and research at the same time, and thus make use of the latest developments in clinical practise whilst also cutting edge medical research. Taiwan’s medical environment was not able to provide such an opportunity at that time. As soon as one left medical school and opened a clinic, there were basically no more opportunities to do medical research. Staying in school to continue research meant students would have to wait a long time before ever finding a stable job with a reliable income.
This issue was more acute for female doctors. The fact that many departments in National Taiwan University Hospital’s clinical ward openly blocked women’s career development and even refused female students entry led many to leave Taiwan after graduation. Ye Shu, the then head of education even noted this at the school of medicine. He stated, “[women are leaving] because America has never tried to block women’s advancement.” In the early post-war years, Taiwan’s resident physician system was the source of multiple forms of discrimination for women. For example, women were often not able to enter their desired medical departments or were forced to resign in the second and third year of residency, as all the opportunities had been given to their male classmates. Those who were hoping to advance could only do so by leaving the hospital or by moving abroad. According to a rough calculation by Hu Kua-cheng, a female doctor who moved to the US after graduating in 1956, over half of the female graduates moved abroad before 1957. In 1957 and 1958, almost all women did.
What do we see when we look back at this early period of doctor outflow? We can all agree that certain push-factors made students want to move abroad and also the pull-factor of a better life and more opportunities abroad. This desire for a “good life” was not all about income; it also included a range of other desires, such as professional goals, political or ideological stances. As such, we can look at the lived experiences of doctors as a way to answer the original question “why do I want to be a doctor?”
Medical education in Taiwan is more developed nowadays. The career paths for doctors and much more diverse and include more research and clinical opportunities. This has created a new generation of well-trained and talented doctors that have turned Taiwan into a society replete with affordable and high-quality medical services. Younger generations do not have to leave the choice for career development as older generations had to. They can apply what they learn to the service of their home country and help out the peoples and communities they come from. The medical environment in Taiwan is indeed facing a somewhat considerable challenge at the moment. Still, becoming a doctor is a career dream for many young people. It is seen as a profession that allows one to make a grand contribution to Taiwanese society that is well-respected and that enjoys substantial benefits. Well-loved figures like Dr Lin. Chieh-liang (who died in 2013) serve as an example of what the profession can be.
If we say that the medical system is facing an enormous crisis, we should not think that the root cause of the crisis is low incomes. Instead, it is a matter of distributive justice and the work environment. If medical bureaucrats always use the slogan of tackling “doctor outflow” as an excuse to create an international medical centre—and thus reduce the professionalism of our medical system as a way to increase profit, making profit and economic growth the primary goals of the medical system—then this will be the real beginning of the end of our medical system.
The history of doctor outflow in Taiwan tells us that doctors of all eras are continually reflecting on what it means to be in the medical profession and what the “good life” of a doctor is. The unique history of Taiwan’s medical system is an essential resource as we come to reflect on the issues of today. This history reminds about the diverse sets of values (not all of which have been good) that have existed within the system. It also provides clues of what a new system might look like. All of us, including medical professional and users of the medical system, should stop for a second to rethink precisely what kind of medical system we want for Taiwan. By doing this, we can begin to retake the power to define medical values away from medical administrations and medical corporations.
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 first part of this article was published Yesterday.