Sunday, June 4, 2017

An untitled mess

Editor's note:

Although I'm on vacation, for some reason this seems to be the week for long, difficult reads on Lao Ren Cha. This isn't as long as my last post, but it was far harder to write and will probably be far more difficult to read. I don't even have a title for it. 

One week before Brendan and I left for a trip that would have me out of Taiwan for over two months, a friend and I sat in the basement-level clinic of the psychiatric ward of National Taiwan University Hospital. Yvonne (not her real name) had been struggling with mental health issues for years, but they had recently gotten worse: she'd been in and out of the ward as a resident several times over the past six months. She hadn't shown up for a planned coffee date, canceled on a small group dinner, was calling or chatting online with a small group of friends, including me but failing consistently to show up in person. I wasn't angry, I was worried about her.

Yvonne was a good friend - health issues aside, she was intelligent (she completed her undergraduate degree at prestigious American liberal arts college and gone on to do a Master’s in Linguistics in Taiwan), loyal and caring. I considered her a good friend - I listened to her, and she to me. When she had an English teaching job and struggled with classroom management, I sat down and gave her a crash course in it, with the idea that as she picked up the basics, more would follow. She pushed me to look seriously into doing a Master’s degree, pointing out that I was full of excuses when the only things really holding me back were nervousness (I'm terrified of people I respect thinking I'm stupid) and money. She was right. We’d met as coworkers at an absolutely horrid “management consulting” company, and spent many an hour excising our bad memories together, stopping when we felt it was starting to get unhealthy. We supported each other and had fun together.

When a mutual friend tipped me off that she had also been skipping her doctor's appointments, I was worried. I feared she'd also been skipping her medication because it interfered with drinking, and I knew she wasn't getting the support she needed. What was scarier was that I wasn't sure what kind of support could reach her.

She was happy to accept my offer to accompany her to her next appointment, which was on a rainy Tuesday morning. I got there first, shook out my umbrella and waited in the old NTU hospital building, the beautiful Japanese-era one. I'd taught a few seminars here once. I'd figured she was less likely to skip an appointment if she knew I'd be there too, and the first step towards some sort of normal that could hold was ensuring she was in regular contact with professionals and taking her medication.

The psychiatry department at NTU is labyrinthine, as are many departments in many hospitals across Taiwan. You go to one window and register, take your registration to the doctor, take something from the doctor's assistant back upstairs, get a number and then wait. There are more papers, trips up-and-down, numbers and queues for payment and medication. I'm not sure how a very ill person - mentally or physically - would be able to manage it alone: most would have to have family, friends or a domestic worker/health aide accompany them. The system is simply not built well for people who are on their own.

I recalled the time when my mother, after having seemingly recovered from the cancer in her lungs, found out that it had spread to her lymphatic system and now she had "months". I was gutted, made plans to return to the US, and thought it would be smart to talk to a grief counselor, or any counselor. I couldn't go to the Community Services Center in Tianmu, because they're only open during weekday business hours and I am simply not able to go to Tianmu during those hours on a regular basis. I found another center closer to home that offered services in English, but they wouldn't let me make an appointment until I chose someone from the list of counselors on their website. Even that was too much of a hurdle, I wasn't in a good state to attempt it. I read through the biographies several times, but kept getting flustered, tired and more depressed. I never called back, and worked through the grief on my own.

If that small stone in the tracks could derail my search for fairly-straightforward counseling when I wasn't even battling a mental illness, just deep grief, imagine the sort of obstacle the back-and-forth of visiting a doctor in a psychiatry ward at a hospital could present to someone in a much more unstable condition.

While we got this upstairs-downstairs workout, we chatted. Yvonne mentioned that she was only able to see a doctor perhaps once a month or for prescription refills, and that today was actually her physician's day to meet new patients. He'd agreed to see her because she'd skipped her last appointment and didn't seem well. She mentioned that she'd tried therapy, but it didn't seem to be yielding fast enough results, and she couldn't afford to keep it up: it's several thousand NT dollars per session, and she was unable to work.

She agreed when I asked her if I could write about her situation, without using her real name, in a post about why mental health services in Taiwan are so deeply lacking. Something needed to be said, but I didn't want to write it while excising the story that caused me to see the problem, and I didn't want to include the story without her consent.

Due to the events that have transpired since then, there is so much more to say. 

On one of our trips back down the stairs, I mentioned that her doctor seemed to be a good professional to have in her corner, as he'd agreed to see her on a day when he did not normally see existing patients. She agreed, but pointed out that during one of her stays in the ward, they'd assigned her a junior doctor who only wanted to talk about her alcoholism. She'd requested a change and the ward had refused - so she drank detergent.

I gasped.

"Well I wanted to make a point. Anyway, I knew it wouldn't kill me," she replied.

A bell should have gone off in my mind then, but didn't. I gathered my composure enough to point out gently that, in fact, drinking detergent could well kill a person.

Back downstairs, waiting for her number to be called, we talked again about therapy. It seemed to be simple common sense that regular contact with professionals - both doctors and counselors, at more frequent intervals than hospital visits could provide - would be a good idea. I didn't have the professional credentials to support Yvonne in the way she needed it, but I hoped I could be supportive in getting her in regular contact with people who did.

She revealed that her boyfriend, who chiefly supported them, was on a leave of absence from work and had his own issues. Although she could not work and was legally classified as 'disabled' and as a result received a small monthly sum from the government, this was just about enough to cover the cost of food and doctor's visits under National Health Insurance. It would not cover therapy, nor a place for her to live when things were not going well with her boyfriend, with whom she'd broken up and gotten back together with several times.

In short, more regular contact with professionals was not something she could afford. National Health Insurance didn't cover it and she had no other means to pay for it. That she desperately needed it - that it might have saved her life - didn't change the cold hard reality of her empty wallet.

The next day, I would speak with a friend who is a psychiatrist, but in an entirely different sub-specialty. She pointed out that, in fact, National Health Insurance does cover therapy in cases like Yvonne's, but the government rate paid to therapists who accept the insurance is something like NT500/hour. This for a professional with graduate-level training. So, clearly, few if any therapists wanted to go through the insurance system. Offering private, non-insured care only, they could charge exponentially more. Unfortunately, this sort of rationalization means that important mental health support is only available to those with means.

As a result, people who need help but can’t afford it like Yvonne have no access. In that way, it’s not that different from the USA, where people do die from lack of access to health care. Praise for Taiwan’s healthcare system is common, especially when compared to the near-total lack of a consistent system in the US, but in this particular way, Taiwan has failed. Family and friends can, in most cases, help someone connect to the right professionals, but consistent access to those professionals is key. If it is not affordable, it is not accessible.

My friend went on to say that, as a result, a lot of psychiatrists whose job would ordinarily be to see a patient in order to determine what sort of medication to prescribe and nothing more - certainly they weren’t paid for more - kept tabs on their patients the way Yvonne’s doctor seemed to be keeping tabs on her. That’s noble, and is one bright light in an otherwise dark landscape, but it really shouldn’t have to come down to that. The care Yvonne and those like her needed shouldn’t have been sparingly provided, at the discretion of a doctor who decides whether or not they’re willing to devote the extra time. That Yvonne had a doctor who did step up is an individual compliment but not praise of Taiwanese healthcare: it speaks to a breakdown of the system that he felt he had to do so in the absence of any other option.

I considered what sort of financial outlay would have been required to band together as friends and just pay for it, but it quickly became clear that it would be too much to ask of mutual friends, with costs approaching what many of them pay for rent each month, for something Yvonne wasn’t very motivated to do. I could give her money (I don’t loan money to friends: I give it, and if I get it back that’s fine. If not, that’s fine too) but not enough to supplant a needed income. 

While waiting for Yvonne’s appointment, I tried to say as gently as I could that the junior doctor who’d wanted to talk about her alcoholism seemed to certainly have had a bad ‘bedside manner’, and I could understand that anyone would be put off by that and by the idea of stopping drinking, but he wasn’t wrong. She did struggle with alcoholism, and it was affecting her medication. Without the medication, however, her mental health would not improve.

Although I’m not a doctor, it did seem clear that, while figuring out her relationship, living and financial situation were important, none of it would hold if she didn’t consistently manage her health.

Yvonne took this well, to my relief. I wondered why the doctor who brought up the subject with her to begin with could not have also broached the topic in a way that she’d have been more likely to be receptive to.

This is not unique to Taiwan: around the world you will find doctors who are empathetic, caring and understanding and can reach patients, and those who don’t make those connections as easily. In Taiwan, that means for every doctor like the one who’d agreed to see Yvonne on an atypical day, and who took care to keep tabs on her situation knowing she had no other professional support, there is likely one whose manner does not meet a patients’ needs.

Yvonne was living with her boyfriend, but it was clear from the instability of that relationship that she would at least need an alternative open to her if it ever did end. Again, Taiwan failed her. She could have stayed with me - and I offered, with Brendan’s support, and gave her a key that she could use anytime - but we both knew it wouldn’t be a good idea to make that permanent. Her disability payments were not enough to cover housing, and her family, who lived in central Taiwan, had long since rejected her (I will not go into their relationship here - I had Yvonne’s consent to write about her situation, but I never asked if I could include her family history, so I won’t).

The disability payments seem designed for people who cannot work but have a place to stay - generally, it is assumed, with family. Although homeless shelters exist, and there are welfare organizations such as Harmony Home for people with specific illnesses (in Harmony Home’s case, HIV/AIDS), a long-term sponsored or subsidized living option does not appear to be available (or widely available - while options may exist, even after several searches I was unable to locate any) to people in Yvonne’s situation. A mutual friend and I discussed whether group living options were available, perhaps with flexible work opportunities for those who might not be able to be reliable as traditional employees, but neither of us could find such a place.

In short, when you have no family to take you in, but no ability to earn enough income to live on your own, there are few if any options available to you in Taiwan. It almost feels as though the healthcare system is designed with the assumption that everyone has family to support them, or with the unconscious belief that if your family has disowned or rejected you, it must somehow be your fault. From simply finding the right care to navigating the hospital system to living day-to-day to paying for services that NHI doesn’t cover, it is assumed you have a support network.

If you don’t…

Yvonne seemed to be in a good mood, or at least a clear mood. We talked about things other than her illness: her cats, her boyfriend, her family, our mutual former employer and how awful they were (they were a part of the reason she was in such a bad financial situation). Music she liked. When we’d meet next, perhaps for dinner or coffee. I pointed out that I was leaving in a week, and it’s likely we wouldn’t be able to meet before then, but if she really needed someone she could always come over, or if she couldn’t manage that, I’d send a taxi to pick her up.

She repeated that she agreed with me that she was going to have to stop drinking and start taking her medication. I knew it wouldn’t be as cut-and-dried as that - wrangling alcoholism and medication rarely are - but as we started to say goodbye, I hoped that at least it was a path she was ready to start down. 

“I really think I’ll be OK, y’know,” she said jus before we parted ways. “Maybe I don’t even need therapy. It’s not like I have suicidal ideation or anything like that.”

At the time I’d been happy to hear a clear indication that she was not considering taking her life. Of course, looking back, that statement was the reddest of flags.

We chatted online a few more times before I left, mostly about nothing terribly important. She said she was feeling up, and other friends agreed she seemed to be doing a bit better. I didn’t reply immediately to her chatty messages, but I did reply. She asked if she was bothering me with ‘chatter’. I said no, I was just working is all, but I’d always respond when I was free. It was true. 

Mutual friends talked about how to support her while I was away, and we thought it’d be okay, at least for the summer. The system was failing her, her family was failing her, her relationship was rocky, but she had us and while we couldn’t replace the full support system she needed, we could do our best to create a basic safety net.

The next week, Brendan and I left for the airport early in the morning. It was May 24th - I would not be back in Taiwan until August 9th. We flew first to Greece, where we enjoyed ourselves as well as seeking out an important piece of my family history.

On our second day there, we were sitting in the cafe near our Airbnb drinking Greek coffee and reading. I was working out how we were going to get to the Athens suburbs the next day. We’d gone to the Acropolis that morning and were sunburned, got lost trying to find a post office, and were planning to go to the Acropolis museum that evening.

Then, I got a message from one of those mutual friends - Yvonne had committed suicide on either May 22nd or 23rd. It would later be determined that she’d taken a number of pills with alcohol.

I sat there, shocked, not knowing how to even begin to process it. For those of you who know me on Facebook, if I sounded unemotional or as though I were unaffected in my upbeat travel posts, it was because my brain went into overtime compartmentalizing, unsure of how to react let alone handle what had happened. 

I’m still not sure how to process it. It feels unreal, as though it didn’t really happen. As I’m not in Taiwan right now, it feels as though I’ll return in August and Yvonne will still be around. I suspect when I return is when the real processing will begin.

I’ve been circling this for a week, unsure of how to write about it, although I knew I wanted to, and know Yvonne had wanted me to write about the system that had so profoundly failed her. I’ve probably painted myself to be an angel in this story, but honestly, I don’t feel I was. I’m neither looking for, nor do I want, sympathy for the pain of losing a friend nor the guilt of feeling like I could have done more. It’s just the truth and ought to be said. I had laid down a boundary that I did not want phone calls after midnight or before 8am (Yvonne had a habit of calling at odd hours and talking for a very long time) - would things have been different if I’d just taken those calls? Or if I’d responded to those final messages more promptly? If I’d searched just a little bit harder for affordable therapy, group living options or anything else that could have helped Yvonne? If I’d been more insistent that I wanted her to stay with us? If I’d given her a bit more money so her financial situation didn’t seem so hopeless? (I’d given her some, not more than I could afford to lose).

Intellectually I know none of these things would have changed much - she needed more help than a few chat messages could have provided - but emotions are slow to follow what the intellect knows.


Or - and this is the key - would it have changed anything if I’d not been so blind to the obvious red flags? Someone seeming like they’re doing a bit better is not a sign that they’re not about to take their life. In fact, it could be a sign that they are. Mentioning twice, unbidden, in one conversation that one is not contemplating suicide is also a clear sign something is wrong. If I’d stopped for half a second to think about it I might have seen that for what it was.

The painful fact remains, however, that the health care system we praise so much - praise which is often, but not always, deserved - failed Yvonne, and it cost her her life. In Taiwan if you don’t have the means to pay for needed treatment that NHI either doesn’t cover or doesn’t cover adequately, and don’t have family to support you, it is a difficult road indeed getting the level of care you need. This is true in terms of physical illnesses - in Taiwan, the hospital staff doesn’t care for you the way they would in other countries (of course, in the US you might not be able to afford a hospital bill). What do you do if you’re in the hospital and have nobody to take care of you, but can’t pay a nurse to care for you either?

It is also true, if not doubly true, for mental illnesses. What do you do if you are so physically or mentally ill that you cannot navigate the maze of windows, queues and numbers at the hospital and have nobody to go with you? What do you do if you need consistent psychological or psychiatric support but cannot afford specific therapies that might be beneficial? What do you do if you can’t work, but have no family to live with? To some extent, these are questions one might face in other countries, especially the USA. The difference is that, unlike the US, Taiwan has a healthcare system that is consistently praised and looked at as a source of national pride.

Looking back, I can see how hopeless Yvonne must have felt. No family, nowhere to live permanently, no way to make money, no way to be independent, insufficient help from the system. Friends who tried to do their best but were ultimately not able to make up for these gaps in the social fabric.

The base assumption really does seem to be that either you are financially independent and can afford what you need on your own, or (more likely) you have family who can do it for you. At the very least, it seems to be assumed that you can live with relatives.

This is not the basis for a modern healthcare system or social welfare system. I’ll always remember Yvonne, but I can’t help but think the system couldn’t have cared less about her. As a result, Taiwan lost one of its smartest, kindest, most loyal citizens, and I lost a good friend. 

No comments: