Friday 20 November 2015

Improving Society in Rural Taiwan


02/11/2015

Taiwan has had dramatic improvements in health. In my view that betokens dramatic improvements in society, along with increased prosperity. A good society will find the route out of poverty as well as caring for those who are disadvantaged in other ways. One way to see this was to visit rural Ilan county, on the coast east of Taiwan.

Shu-Ti Chiou has many strings to her bow. She had been health commissioner for Ilan before moving to Taipei. Last year she was prevailed upon to run for mayor in Ilan. She didn’t win, but received campaign expenses proportional to the votes she achieved. She used the money to start a small foundation to promote better health in Ilan.

On a Saturday morning we were taken to Yutian elementary school, to be met by the charismatic head teacher. He was clad in cycling gear, because Shu-Ti’s foundation had a collection of school principles set an inspiring example by doing a prolonged cycling trip, ending up at the Eden Foundation Yilan school – see below.

Two highlights of the school. First, it might be in a poor rural area, but the head teacher was committed to using technology appropriately. Each child was issued with a tablet computer to use at school and home. It was an integral part of the classroom as well as forming a close link between school and home.

Second, after a tour of the lovely school building we had a tea break – no ordinary tea break. Two youngsters performed the Taiwan version of the tea ceremony.  I asked if it was modeled on the Japanese tea ceremony and was told firmly: no, the Japanese got it from the Chinese. It really is a wonderful interlude to a busy day. No dunking of a British Rail tea bag into a mug of boiling water and going back to your desk. The student laid out five cups for the four ‘guests’ and herself, then slowly, methodically, and with practiced movements went through the ritual: warming the receptacle – perhaps best described as a porcelain squat jug; putting tea leaves into it, pouring water on, then discarding immediately – apparently this removes dust from the tea, and perhaps some unpleasant taste; then pouring a new lot of water on the leaves; then filling the small cups – which of course are in the same style of porcelain as the jug. All this is accomplished in absolute silence which adds to the meditative quality of it. Fifteen minutes of this and not only have you had a refreshing tea but you feel calmer, more meditative.


Then onto the Yilan Branch of the Taiwan Fund for Families and Children. Children from disturbed families are brought into the place. If because of their disrupted backgrounds, they are doing badly in school, they will actually attend school on the premises. We were treated to a drumming display by a group of these children who were clearly committed to what they were doing. It is a lovely place. One special area, no shoes, colourful but calming, is where young people can go if they are feeling angry or upset; or where they go with a counsellor.

I asked, I would  wouldn’t I, if they had any measures of success or otherwise of their various activities. Probably not, but it certainly gives children a place to be, to have fun and/or meaningful activities, and to feel a little bit of love from the warm committed social workers in the place.


Last stop was the Eden Foundation Yilan School. It is for educationally subnormal children and young adults. As with our previous two stops, the overwhelming feeling was that of staff who cared. The head teachers arrived on their bicycles and put on a concert for the residents, who appeared most appreciative.

I don’t know how typical these three special places are of what goes on throughout the country, but if this is how the poor, the disturbed and the mentally subnormal are treated, then the country has a great deal going for it.




Doing Better in Taiwan

01/11/2015

Politics? Yes, of course, politics. It is always there. But, we argue consistently that concern with health should trump concern with diplomatic political sensitivities. I said it at the World Medical Association General Medical Assembly in Moscow: whatever tensions there may be between Russia and other countries, we work together in the common cause of better health. And it is what I felt when we at the IHE were approached by the Health Promotion Department of the Taiwan government to write a report on how they could address persistent health inequities through action on the social determinants of health. Does that mean we take a view about the continued aggravation about China and Taiwan? Not at all. We would be happy to work with China as we are with Taiwan. (For the Eastern Mediterranean Region of WHO, I have been to Egypt, Morocco, Iran and Tunisia; and joined a meeting in Kuwait by Skype. For WHO Euro I have been to Israel. Health is a shared concern.)

When on a Friday morning, I found myself sharing a joke with President Ma of Taiwan – see photo – my concern was not with international diplomacy but to secure his agreement to whole of government approaches to social determinants of health and health equity. He and I signed a mock-up of the cover of our report for Taiwan.



If we take the ‘do something, do more, do better’ mantra to Taiwan, we would have to say, they are in the latter group. Taiwan has done remarkably well. Life expectancy for men is 77 and for women, 83. This would put them firmly in the European average. A huge improvement remarkably quickly. But health inequalities persist – seen in the social gradient in life expectancy and disability-free life expectancy.

The Director-General of the Health Promotion Administration of the Ministry of Health and Welfare, Shu-Ti Chou, is a charismatic figure – see third photo. Committed, perceptive, well-informed, and clearly loved and admired by her colleagues. I apologised for the depths of my ignorance of Chinese names, but I told her that her name reminded me of the two names in Bertold Brecht’s play, The Good Person of Szechuan. Shen Te was good, caring and generous. But people took advantage of her good nature. She invented an alter ego, Shui Ta, who displayed the more self-centred side of human nature to protect herself. Shu-Ti said that perhaps she embodied a bit of both, caring and concerned, empathetic and embodying better virtues but at the same time having the drive necessary to make progress.


As well as the publicly stated commitment from the President, there is a potentially viable mechanism in Taiwan for whole of government action on SDH: the Committee on Sustainable Development. This committee is chaired by the Prime Minister and has the sustainable development focus of environment, economy and social development. By getting health equity into the last of these three and linking it firmly to the other two, there is reall prospect of making progress.


We plan to work with Taiwan over the coming year as they seek to make progress.








Thursday 12 November 2015

Harmony and Action in the Caribbean


A population made up of indigenous people, escaped African slaves, French, Spanish and English colonialists, Creoles (mix of Europeans and Africans), Javanese, East Indians, and then sprinklings of Jews, Chinese, Brazilians and a few others – what language do you imagine they might speak?

Why Dutch, of course. This is Suriname, now independent of the Netherlands. It wasn’t always a Dutch colony. In the 17th century the English got New Amsterdam from the Dutch and the Dutch got Suriname from the English. Who got the best of that deal? New Amsterdam, of course, became New York.

Check the map. Suriname is up there on the Caribbean coast of South America between French Guiana and (British) Guiana. It’s capital as every school child knows, well some do, is Paramaribo.

Suriname is special not only because it is the only Dutch-speaking country in South America but it has a population of just over 500,000 and vast swathes of pristine tropical forest. Like much of South America it has a chequered past. But it is now a democracy. I was there, at the invitation of PAHO (Pan American Health Organization), because the government of Suriname has taken on board the importance of social determinants of health and action through, Health in All Policies (HIAP).

Francoise Barten, who I met first at the People’s Health Assembly in Cuenca, Ecuador in 2005, was there to greet me on behalf of PAHO.

The government really are engaged. After a meeting with the Minister of Health I was hosted by the Speaker in the House of Assembly, the Parliament, and gave a lecture to the House on social determinants of health. The next day, at a big national meeting, especially big for a tiny country, the Vice-President, Minister of Foreign Affairs, Minister of Health and Speaker of the House were all there. I have been invited to give a keynote address before, with ministers on the platform. They usually give their speech and leave. A noble exception was the Swedish Minister of Health. This time the ministers all stayed at least for the morning session.

I was also hosted by the Suriname Medical Association and the Faculty of Medicine and gave a talk on The Health Gap.




Above: With First Lady of Suriname, Liliane Ferrier, and Guillermo Troya, PAHO Rep in Suriname

I met the first lady who is leading a country-wide initiative on early child development. We had a good meeting. The First Lady said that she was also the champion across government for HIAP. I told her that I think Suriname is showing the way on whole of government action on SDH. Impressive.

With the First Lady at our meeting was psychologist, Liliane Ferrier who had said to me publicly at the big meeting: I have been waiting for you in Suriname for 25 years!

A little insight into the country. The doctors gave me two books by a Surinamese novelist Cynthia McCleod. McCleod? In Suriname? A little research revealed that her unmarried name was Ferrier and she was the daughter of a President of the country. Liliane is a Ferrier. Any relation? Yes. First cousin. The former President was her uncle. Liliane’s background included Jewish, Chinese, and a lot else besides, including time spent in the Netherlands.

There is great willingness and interest on the part of government to be active on social determinants of health. An important step is good documentation of the extent of inequalities in health and in the determinants of health.

We may well do some work with them in evaluation of their initiatives on early child development.