Saturday, June 20, 2009

Taiwan for a Day

When the famous New York Times columnist Thomas Friedman wrote his recent 2008 book Hot, Flat, and Crowded and spoke out loudly in frustration that he wishes America can be China for a day so that Green Revolution can be realized. I wonder if he had paid attention to health care, another critical issue to American’s long term future, would he have declared “Let us be Taiwan for a Day”?

Health care reform is on top of the heap right now for White House and the Congress, first time in 16 years since the failed Clinton attempt. After years of avoidance and run-away financial burden, there is now a sense of urgency by the public especially as the current recession and unemployment situation brought the attention of the devastation of loss of health care coverage. While everyone agrees that an overhaul is needed now, it is highly questionable that a fundamental and effective solution would be found this time given the historical baggage and the way the political system works.

The latest news from Washington D.C. is not encouraging. The hope of getting a good bill passed through the Senate Committees or House Committees before their recess in July seems in doubt as there appear to be no consensus among the legislators and interested parties. Worse, the head wind of the concern for increased federal budget deficit is getting stronger. It is possible that significant political compromise in coverage or budget will have to be made such that the odds of having a once-and-for-all successful fix of the health care system is diminishing. Will we be witnessing the country be dragged down by the exploding cost of the health care as we argue endlessly with each other on how to fix the problem?

The most talked-about success story of health care system reform is what took place in Taiwan back in 1995 that borrowed a lot of ideas from the American Medicare system. What is the chance that we can find a solution that will do as well or close to it? Can America reinvent itself?

Taiwan’s universal health care began the efforts of re-architecting its health care system in 1980’s after its economy and wealth have undergone two decades of rapid growth. Research and planning efforts went into high gear in 1993 (the year Clinton launched his), partly in response to the competing policy campaign by the newly formed opposition party. In less than 2 years, the National Health Insurance (NHI) program was established and rushed into service in 1995 with a few bumps that covers now practically the whole 23+ million populations including guest workers.

What is so great about Taiwan’s health care system that earned the envy and praise by so many public health professionals, economists, and political figures alike worldwide? Beyond the complete care from preventative through dental, drugs to home care, ease of access to and choice of providers got to top the list from patients’ perspective. Indeed, anyone in Taiwan can walk into any of the private or public clinics and hospitals at any time (yes, some open in weekend and evenings) to see any doctor or specialists of his/her choice. No, there is no pre-authorization or referral required with minor but reasonable exceptions. Yes, if you want to see a popular doctor, you would likely need to make a reservation in advance - a result of supply and demand. Further, out of pocket co-pay is about $2 - $5 U.S. dollars per visit that is roughly the cost of having a simple but decent lunch there. Similarly there is a small amount of capped co-pay for prescription drugs.

The possibility of “doctor-shopping” and walk-in service was enabled with a smart-card that every participants gets that allows providers access patients’ basic data and health record as well performing updates and billing electronically through the single payer – the Bureau of National Health Insurance who administers and monitors the health of the system. The administrative cost is so low (less than 2%!) that makes you wonder how could it be good when we are paying a 20% overhead for such a function in U.S.. Is that the price for having a free market and private insurance companies? What values do these health insurance companies add? Why do we need so many middlemen? As Harvard Professor Michael Porter pointed out, one of the major problems with our health care system is that it has the wrong form of competition; a zero-sum as opposed to value-based competition which seems what Taiwan has found.

The bottom line is that for all the benefits, Taiwan’s NHI comes at a total price tag of ~6% of Taiwan’s GDP, compared to ~16% in U.S (or $1K vs. $7K per capita per year). Granted it is currently underfunded, some studies suggest an increase to 8% of GDP would keep it financially sound. By the way, NHI is funded by three parties, roughly around 1/3 each in increasing order: Government (~27%), employer’s contribution (similar to the Social Security Tax system in U.S.), participants (for those who are not employed, he/she is required to participate in the system with a premium of ~20 U.S. dollars per month. If that is not affordable, government will supplement it or pay for it completely). Isn’t it nice that if one does not need to worry about losing their health care if he/she is not employed or lost their jobs?

Of course, no system is perfect, and Taiwan’s NHI does have rooms for improvements that require cost tradeoffs. Of course, I know that the first objection to it for U.S. is the fact that it is a “single payer system”. Many politicians and business men have successfully scare us about involving government in “heath care business” and labeled it with “socialized medicine” and “rationing”. But people are not machines and health care insurance is not like auto insurance or any other business. We do have social responsibility for it to our children, their children, and fellow citizens! What is wrong with a “socialized medicine” if it can be made available effectively to all while delivered by private providers that compete in open markets and freely chosen by patients? Do we rather spiral down into bankruptcy and suffer in quality of life than enjoy an anxiety-free health care system at a lower cost? Do we rather have an inefficient system that does not encourage productive use of resources and real competition just for the namesake?

Before I go, I’d like to leave you the Hippocratic Oath that laid the fundamental principle of the health care 2500 years ago. A modern version of it widely used by many medical schools in U.S. is included below. It is my opinion that any part of a health care system that does not subscribe to or support this oath has no place in it. To me, this is the obvious place to start in any health care system reform. Talk to you soon!

A Modern Version of Hippocratic Oath
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Saturday, June 13, 2009

Exile or Not?

After the bloody crackdown of the 1989 June Fourth Protest at the Tiananmen Square, arrests and persecutions for those who were involved in the "counter-revolutionary rebellion" began in earnest across China. The most well-known nation-wide men-hunt was for the so-called “21 Most-Wanted List”, originated from Beijing City Public Security Bureau. Most of these leaders were around 20 years old and all but one was university students. In the May 31th issue of World News Weekly世界周刊, a Chinese publication in America, there was an article by one of them - Feng ConDe封從德who provided an update of these individuals.

It is interesting to look at some statistics based on that article. Out of these “21 most-wanted”, 7 successfully escaped the country to France or U.S. via Hong Kong within the following 2 years after the protest. Out of these 7 escaped, two of them now reside in Taiwan and the rest are in U.S. The remaining 14 were arrested, imprisoned and harassed regularly or re-arrested after releases. Out of these 14, eventually 7 of them were exiled (by Chinese Government) or escaped on their own to U.S. The other 7 are still in China and at least one of them has openly declared that he does not wish to leave China. A majority of these 21 now are engaged in various fields ranging from science/technology to financial investments. While they continue to believe in the cause, only few of them appear to be able to devote significant amount of time or energy to stay active with it.

Upon reading the news reports, I can’t stop wondering how each of them have felt about their choices over the last two decades, in particular, the dilemma of exile (to other countries) or staying in China? Would one be able to achieve more staying alive but isolated in prison? Would one be able to do more going abroad, living and speaking freely?

Perhaps it is useful to digress and look at some inspirational figures and symbols of recent history in the world who had led the fights against the regimes in search of rights including freedom, democracy, and self-determination.

The first one comes to mind is Nelson Mandela of South Africa. He was an anti-apartheid activist and the leader of the African National Congress's armed wing Umkhonto we Sizwe (yes, he one time was pursuing bombing and guerilla warfare tactics.) He spent 27 years in prison (1964-1990) and after the release, led the successful negotiations to end the apartheid peacefully and hold the first multi-racial election. He was awarded the Nobel Peace Prize in 1993 and became South Africa’s first black president in 1994. His unwavering belief of a multi-race democratically governed South Africa enabled the healings and peaceful transition of the power.

Incidentally Mandela was influenced by Mahatma Gandhi, father of India, lived in South Africa from 1893 to 1913 where he began his non-violent civil disobedience campaign as an expatriate lawyer in the resident Indian community's struggle for civil rights. He returned to India in 1915 and led the successful Indian Independent Movement with Non-cooperation movement, no small task for a historically divided and fragmented nation consisted of many kingdoms and tribes. Ghandi had been imprisoned many times and many years in both South Africa and India. He was assassinated in Jan 1948, shortly after overseeing the declaration of independence of India from Great Britain. His non-violent and passive resistance approach worked effectively with the culture despite with a very diverse and divided society.

The first Southeast Asian figure comes to mind is Aung San Suu Kyi of Myanmar (formerly Burma), a pro-democratic activist and political leader. She was to become the Prime Minister after her party won an overwhelming victory in the 1990 general election, the first since 1960. However the Military Junta would not acknowledge the result of the election and instead held her under house arrest on and off for a total of 13 years since then. She was awarded the Nobel Peace Prize in 1991. Aung San Suu Kyi has consistently refused Military Junta’s offer to leave the country and chosen instead to continue the fight for democracy and freedom from within. With her stature and personal sacrifice, she has been able to keep world’s attention and pressure on the repressive military dictatorship of Myanmar.

For the totalitarian and now dissolved Soviet Union, Andrei Sakharov, a human rights activist and 1975 Nobel Peace Prize winner had experienced similar reprisals to those in other countries including isolation, internal exile and imprisonment. He was a trained nuclear physicist and became active first in anti nuclear proliferation.

A more intriguing icon of Sakharov's countrymen is a non-political figurethe, the 1970 Nobel Literature Laureate Aleksandr Solzhenitsyn whose 3 volume seminal work The Gulag Archipelago were sneaked out and became available in the West in 1973. Some have noted that the work has single handedly indicted the Soviet Union totalitarian system and stopped the proliferation of communism in Europe. He was exiled in 1974 and returned to Russia in 1994 after the breakup of Soviet Union. Unlike many, he has been vocal and critical to aspects of Western culture and remained as a strong believer in Russian Nationalism and Orthodox Church.

Closer to China, there are examples from Taiwan and Tibet. The 14th Dalai Lama , the1989 Nobel Peace Prize winner, left the theological Tibet in 1959 and exiled to India at age 9 when Communist China took over the control of Tibet Autonomous Region. Since then he has been heading the Tibet exile government (in India) and pushing for the autonomy of Tibet through peaceful means. His moderate position and approach has not been met with reciprocity from Communist China nor welcomed by more militant factions of the independence movement. His personal charm and popularity are not likely to be passed onto his successors. Further, time is not his side.

In Taiwan, first person comes to mind is Peng MinMing彭明敏 who is often considered the Godfather of Taiwan Independence Movement for his 1964 “Declaration On Taiwan Self-Salvation Movement”. Peng was arrested, jailed and later released a year later under house arrest till January 1970 when he escaped from Taiwan and received political asylum in Sweden. He later moved to U.S. and did not return to Taiwan until 1991 after the martial law was lifted. He ran unsuccessfully for President as the opposition party DPP candidate in 1996 (against Lee DengHui of Nationalist Party). While he was an early leader of Taiwan Independence Movement, his loss in the popular election after long absence from Taiwan does suggest how one could lose his/her political bases from an exile.

Another important figure of Taiwan is Shi MingDeh 施明德, a long time champion and leader of democratic movements and anti-authoritarian power. Twice sentenced to life-in-prison, he spent over 25 years in jail in total before he reached the age of 50 in 1991. Refused to be paroled, pardoned several times and eventually unconditionally released, he is quite a principled man and remains to be the conscience of Taiwan. He led the anti-corruption demonstration of 2006 against the DPP government (of which he was one time the party chairman) and attracted, by some account, more than one million participants.

All these well-known examples and others do not seem to suggest obvious answers to the dilemma of exile if and when one faces it. On one hand, exile would keep you and your dream alive. It allows for the continuing development of the ideals and often the freedom of dissemination of one’s belief and ideas. It is thus easier to gather resources and persuade others outside the country to support or join the cause. However in gaining such freedoms, exile would make it difficult to get attention of your countrymen who after all, are the ones care most about domestic politics and development. At the emotional level, I could imagine it is hard to run away and stay alive with the burden of bearing witness of the dead and the continuing struggle. Yet, what is the use of sacrificing one’s life if that would not advance the cause? . We can never second guess the choice by each one of them.

Indeed there is really no right or wrong choice and we should never second guess the choice made. At the end, the cause and ideals are bigger than individuals and are what count. Growing and speaking out is always better than being ignorant or staying silent. One thing for sure though reform and changes can only be successful ultimately from within.

Talk to you soon!

Thursday, June 11, 2009

From May Fourth to June Fourth 從五四到六四

Last time we talked about the 90th anniversary of May Fourth Demonstration when I was in Taipei. In a blink, the 20th anniversary of the June Fourth Tiananmen Square Protest has already passed. For those who are familiar with the history of Chinese Communist Party, the founding of it in 1921 (by Chen DuXiu陳獨秀and Li DaZhao李大釗) was a direct result of the May Fourth movement. It is ironic that Chinese Communist Party who is known for advancing its political agenda using student’s sentiment and movements ended up being humiliated and challenged 70 years later on June Fourth by another student-led protest. I suppose this is another validation of the old saying “Live by the Sword, Die by the Sword”.

After the bloody crackdown of the June Fourth Protest at the Tiananmen Square, persecutions and arrests for those who were involved in the “anti-government” activities began across China. The most well-known nation-wide men-hunt was the so-called “21 Most-Wanted List” originated from Beijing City Security Department. Most of them were around 20 years old and all but one were university students. In the May 31th issue of World News Weekly世界周刊, a Chinese publication in America, there was an article by Feng ConDe封從德that provided an update of those individuals.

It is useful to look at some statistics based on that article. Out of these 21 “most-wanted”, 7 successfully escaped the country to France or U.S. via Hong Kong within the following 2 years after the protest. Out of these 7 escaped, two of them now reside in Taiwan and the rest are in U.S. The remaining 14 were arrested, jailed and harassed regularly and 7 of them were subsequently exiled or escaped to U.S. The other 7 are still in China and at least one of them has openly declared that he does not wish to leave China. A majority of these 21 now are engaged in various fields ranging from science/technology to financial investments. While they continue to believe in the cause, only few of them appear to be able to devote significant amount of time or energy to stay active with it. It is also not clear despite the press and reminders, there is much traction or momentum inside or outside China.

Will the June Fourth protests be like a comet: a shinning flash over the sky and then forgotten? Why does May Fourth Movement still get discussed and its impacts felt after 90 years while June Fourth already shown signs of aging at 20 year old?

Although in both cases many leaders and participants were elite college students and intellects, I see at least three significant differences.

The first is the scope: May Fourth demonstration is a historical moment that accelerated the critical examinations of political, cultural, social systems and underlying theory in response to the need for modernization of China. On the other hand, the agenda of June Fourth protests was mainly on the reform of the authoritarian political system, as Chinese Communist Party under Deng’s reign had begun reforms of its economic system since 1978. While political freedom and empowerment is inevitable with a successful economic reform (that empowers and incent individuals to increase the productions), there wasn’t any serious discussion or consensus for the reform of its political system. While the progressives were sympathetic to students’ frustrations and feelings, the demands were definitely seen by the hardliners as a direct challenge to the party authority and power. The confusions within both sides and escalations helped put the mass and hardliners on a collision course that ended with a bloody crackdown in name of maintaining stability.

The second is the environment: In early 20th century China, there was tremendous chaos and many competing factions as the country had just emerged from a revolution that ended thousands of years of monarchies. There were so much to be done with the systems and so little resources and experiences. This affords opportunities for the intellectuals, politicians, and warlords alike to develop diverse views and directions. In contrast, before June Fourth, Communist Party has ruled China for half a century began with a totalitarian system. There has been an extremely tight control of access and communications to information and ideas and very little room for intellectuals and students to thrive.

The third significant difference is the development of leaders. Many of the student leaders of May Fourth Movement had continued their work and studies abroad and in China in relevant fields such as philosophy, literature, language, laws, social and political science after the demonstration. Some went on to become leaders in academics, research institutions, and political parties. Most importantly, they have passed on their torches to next generations through teaching, writing and public debates for a historical task. In contrast, many of the leaders of June Fourth Protest appear to have ended up making a living like the rest of the world in a variety of fields. Their talents can clearly be seen, independent of what they had chosen to do. This result could be personal choice and interest. It could also be due to the difficulty in getting financial and moral supports to stay on the subjects.

The reality is we should not have unrealistic expectations for this group of brave and bright young people of the June Fourth as we admire their courage. Many of them have paid a tremendous price and still bear the burden of a dream that has yet to be realized. The more important question is where should this energy be directed at? It is too early to write the history of June Fourth protests. However the only way June Fourth will be remembered with more than a candlelight vigil annually decades from now is for the leaders and the supporters to return to the fundamental issue: to crystallize the ideals and show the ways for reform of the Chinese political system. It is not too late nor too early as China is becoming prosperous. That would be the best way to pay tributes to those who put their bodies and minds on the line.

Talk to you soon!