Why are Taiwan's emergency rooms overflowing?

 

The photo isn't really related to the post; I took it in Japan last year. But I like the visual concept

A friend’s husband was recently in a serious accident.

"Well, fortunately we're in Taiwan," you might think, "so he'll get a stay in the hospital and effective treatment, and it won't cost much."  After all, Taiwan’s accessible, affordable healthcare is consistently well-ranked. The Taiwanese public seems to agree: in general, satisfaction with the system reaches heights that most Western nations could only dream of, reaching almost 90% in 2019. All of this is possible through far less government expenditure than in most other nations, including the US – just 6.6% of GDP. Despite this, you'd only be partially right.

My friend’s husband will indeed get affordable treatment. However, he ended up spending two days and two nights in the emergency room, in critical condition, before he was allocated a hospital bed. And his condition was -- is -- so serious that he'd been put at the front of the queue to get that bed at all! My friend had some very complicated feelings about this, noting that others had been in the ER for even longer. Some would be waiting for a bed for up to a week. 

It's not news that Taiwan has a hospital bed shortage. News outlets have been reporting on it for at least a year. A physician who spoke to United Daily News earlier this year estimated that 10-20% of hospital wards have closed. In 2023, CommonWealth reported that emergency room stays lasting more than a night had tripled, and the wait for hospital beds had doubled. Around the same time, TaiwanPlus pointed to Taipei’s Mackay Memorial Hospital closing 200 beds.

How does a system that was founded on the idea of streamlined access, and informed by research on the benefits and drawbacks of systems in other countries, end up with such a massive bed shortage, and emergency room visits that, in some cases, are as long as typical hospital stays?

The surface-level cause is clear: insufficient nursing staff to attend to the patients who would usually occupy those rooms. Nurses are quitting in droves, they say, resulting in crisis-level turnover. Taiwan regulates the nurse-to-patient ratio at approximately 1:9, with higher patient loads during the day and lower ones at night. A shortage of nurses, therefore, translates directly into insufficient beds.  

The reasons for this mass exodus are as predictable as they are insidious: as with female-dominated professions in general, nurses in Taiwan are overworked and underpaid. Taiwanese nurses are frequently asked to do overtime and have trouble taking time off, but even experienced ones earn on average just $46,000-$55,000NT per month. Although Taiwan graduates more nurses than it needs, so many quit the profession out of frustration, exhaustion or both that new graduates aren’t stemming the shortage. Despite a surfeit of students studying nursing, Taiwan is almost always several thousand nurses short of what it needs for its hospitals to function at capacity. Taiwan has approximately 310,000 registered nurses, but only about 60% are currently working.

The good thing about obvious problems, one would think, is that they tend to come with obvious solutions. Offer better working conditions with less overtime for more pay, and all of those nursing students will remain nurses. Despite this blindingly obvious fix to a problem that should have never existed in the first place, the media, the government and hospital leadership all seem to be giving themselves enemas with their own heads. 

Initially, the government threw money at the problem without taking concrete steps to ensure nurses were paid well to work reasonable hours. Billions were given to hospitals through the 2010s to address the shortage; slightly less than half of those hospitals hired more nurses or increased pay. Many did nothing, or decreased their nursing staff.   Last year, the government also announced plans to ease the examination requirements for new nurses. While allowing nurses who would have otherwise failed the exam to practice seems likely to lower-quality care, the bigger issue is that it doesn't solve the core problem: bringing in more nurses won't stop the hemorrhaging on the other end. If nurses are not paid well to work reasonable hours, even potentially less-skilled ones will eventually quit.

More recently, the government has introduced new rules that increase the nurse-to-patient ratio and overall offer night shift bonuses. Of course, higher patient loads only increase stress on nurses, and bonuses to keep nurses working to their physical breaking points do nothing to address the overwork causing them to quit in the first place. Quite the opposite, in fact.

Different levels of hospitals can offer different bonuses to nurses; unsurprisingly, district hospitals, where nurses have the highest patient load, would offer the lowest bonuses.

As one might predict, nurses aren’t keen on the scheme. Nearly 57% “reject” it, saying it won’t alleviate the shortage, isn’t fair to day nurses, and will make scheduling shifts even more difficult. 

Apparently “pay nurses fair wages to work reasonable hours” is simply too difficult for those in power to comprehend.

Taiwanese media isn’t helping much to report on the issue. UDN mentions overwork, but doesn’t discuss improved pay and promotion schemes. Instead, it examines the enrollment quota for nursing students and recommends improving safety measures, neither of which are in the same galaxy as the real problem. In the Liberty Times, the head of the Yunlin branch of National Taiwan University Hospital suggests streamlining nurses’ work to make it more efficient and less repetitive. While this isn’t a bad idea, it’s also, still, not the problem. 

Chi Shu-ching of the Taiwan Union of Nurses Association said recently that there is "no one policy that will replenish the ranks [of nurses] straightaway", but that's not entirely true. Though it will also take some time, the obvious solution of paying nurses more to work reasonable hours will be the fastest possible way to convince nursing students not to quit their programs, and registered nurses to stay or return to the field. The government keeps setting aside funds for other initiatives and incentives, so clearly it's willing to throw money at the problem. How about throwing some of that money at nurse remuneration, and not just in exchange for more work? In other words, everyone seems to know "why" Taiwan has a nursing shortage that seems more entrenched and unsolvable each year, but few really seem to understand why.

Or perhaps they do, but they can’t bring themselves to pay women a fair wage for reasonable hours of professional work. Until this changes, Taiwan may well not live up to its global reputation for accessible, prompt healthcare.

Blood Sugar Hex Magic

                       

Yes, it's a punny title, but I won't change it. 

It felt like magic when I began losing weight without trying. Several months out from COVID recovery, I'd changed exactly one habit: I was drinking an average of two liters of water per day. Before COVID I had a small water bottle for going out; by the time I'd sipped it dry I could usually find a place ot refill it. Now, I could down that thing in three gulps, and was instead bringing a full liter everywhere I went. I'd have to refill that as well. I assumed that my wholesome new drinking habit was the driver of the weight loss. 

I had to have pants taken in and shirts re-tailored. I bought a belt. Even my shoes fit a little looser. From July to November, I lost a dress size. By January, it was a size and a half. As of now, it might be two.

I won't lie: it felt great. I didn't have any other issues or symptoms, so I just kept on assuming it was all that water. It's no secret that I'm -- what are we calling it these days? Curvy? -- and it was thrilling to be dropping pounds. Who wouldn't want that, especially with very little effort? 

Most cultures these days seem to be weight-conscious. People will say it's about health but it's really not. It's straight-up "NO FATTIES" judgmentalism. If you're fat and healthy that's still insufficient. If you're thin and sick, you should handle that, but it's ultimately better than being fat. There are people who will argue with the idea that this is totally fucked up, and that's fucked up too. 

Taiwan is no different. Taiwanese society's obsession with weight isn't even unique: you'll find pills and horrible diets and people -- mostly women -- taking on unhealthy habits and getting surgery in every other Asian country and many, if not most, places beyond. Although the country of my birth is somewhat fatter on average, all of these things exist there too. If you needed any evidence that none of it works, there it is: the United States has the juice cleanses, the disgusting powders, the gross teas and the weird contraptions too, and Americans aren't getting any thinner. 

The main difference I've found is that Taiwanese standards for being thin are far stricter: you have to be a stick to even fit into the clothing sizes available. Large-size stores exist, but they don't work for me as I'm too tall for the hemlines and the cuts don't take curves into account.

People (usually women) who are average or even slender have told me that they're regularly called fat. One told me a guy walked away because he believed he should be able to wrap his hands around her waist and have his fingers touch, which is some eating-disorder level bullshit.  I've heard far too many people commenting on weight as though it's a moral failing in an infuriatingly matter-of-fact way, and include people who are simply not fat in that definition (not that it would be any more acceptable if they didn't). 

If you're a foreign woman, it's unlikely that you'll meet these size standards. Even thin Western women I know have said they feel like giants here. Trust me, it's even harder when you're a Big Foreign Sasquatch. In addition to local messaging, there's a big community of misogynist Western dudes who have the "no fatties!" mindset. Fortunately, they mostly ignore expat women they deem overweight. They don't seem to realize they're handing us a gift.

It's to the point that seeing a doctor can be an exercise in stress, when medical professionals ought to focus on treatment. It felt like being cursed, or hexed: presenting for care, being told to lose weight and possibly receiving substandard care from a doctor who assumed weight loss was the only possible treatment, feeling like trash about it, and avoiding seeking further care. People say being overweight can lead to lower life expectancy, but I wonder if seeking medical treatment less often, and receiving insufficient treatment when one does, might lead to medical conditions spinning out of control that didn't need to be life-threatening in the first place.

Although I don't really want to speak Mandarin when there's a contraption that looks like a wine key stuck up my vagina, I quit one English-speaking OB-GYN and sought out another, because her only suggestion for treating my cystic ovaries was to lose weight. Of course, the cystic ovaries probably contribute to the weight in the first place. 

When I got COVID, I asked for Paxlovid as I was feeling weird in the general heart area, which is generally not considered to be a good thing. I have a family history of heart problems (though as far as I know, I'm fine), but that wasn't enough. The telemedicine doctor said it didn't qualify. So I said "oh, but I'm fat!" and got the drugs: having a likely predisposition to vascular issues was insufficient, but weight was. The doctor also said that heart problems were associated with obesity, and I didn't have it in me to reply my family members with heart issues were not fat, with no exceptions. 

I don't want to single out Taiwan, though. Fat people are treated like crap by society and medical professionals around the world. A doctor in the US whom I saw because I tested positive for tuberculosis exposure (I never developed the disease) exhorted me to lose weight, in college, when I wasn't fat. The main difference is that in the US people will talk about "fatties" (or "fat chicks", because this is mostly aimed at women) in derogatory ways to no-one in particular. In Taiwan they'll be more straightforward about it, but are more likely to say it to your face. 

In Taiwan, my tailor and one doctor congratulated me on my weight loss. Foreign friends said I should get checked out as my water consumption was atypical, others didn't see a concern: drinking that much of a calorie-free substance is a common weight-loss tactic!

Here's the truly unhealthy part: I didn't want this to be a problem. Of course no one does, but specifically I was quite happy to continue slimming down. A tiny voice in the back of my head kept prodding me -- you know they're right. Water or not, my rate of weight loss wasn't normal or healthy. And yet, as much work as I've done to simply love myself and focus on being a person rather than a number on a scale, I wanted to keep losing it. Going to the gym hadn't worked. Eating better never worked either. Why not take this gift being handed to me?

It gets worse: walking around in my slimmer body, I didn't just feel better about myself, I felt healthy. After all, losing weight is healthy, right? Slimmer people are healthier, no?

This was in fact extremely dangerous. I was not healthy. But when society tells you that dropping a size or two is good for you, it's extremely hard to break away and say no, something's wrong.

I visited the US recently, and it took an old college friend to really hammer it home: I needed to see a doctor. Excessive water consumption and unexplained weight loss were the most common symptoms of high blood sugar and diabetes. Even then, thinking back on years in Taiwan being matter-of-factly told I was fat, with insane diets and life-consuming exercise regimes suggested as a "cure", I secretly hoped that I would be able to "keep" the weight loss.

And yes, I did find the anti-fat messaging in Taiwan more damaging. That could just be me: it's easy to ignore Internet chuds in the US screeching about "fat chicks", usually with some assumption that said fat chicks would be single forever. Who cares? I'm not single!

It's harder to not let oneself be affected by a straight-up proclamation that you are fat and that is bad. The advertising affected me more too. It's harmful enough that the US has re-vamped all its weight-loss marketing as "wellness" or "health" (I'm sorry but nasty drinks and no food are not healthy, period). In Taiwan, well, you are fat and that is bad.

For someone who's worked hard to break free of mindsets like these, it really shows how deeply this societal messaging runs, and how damaging it can be. I came very close to not seeking care because I thought of weight loss as an unequivocal good! 

I should have known better. You know who else lost a lot of weight because she was sick? My mother, just before the cancer came back. She's no longer with us.

I did make an appointment with an endocrinologist after returning to Taiwan. You know what it took to do that? A friend treating my new body as a warning sign rather than something to be congratulated. I should not have needed that hard a push. I also massively cut down my sugar intake and reduced my carbohydrate intake, although it's hard to sustain that with no clear diagnosis. It was especially hard as my first week doing this was in Mexico, where the chocolate and the churros are delicious. 

You know what? Even then, I fretted about it the day before and morning of, simply because I wasn't in a good mental place to be told yet again that I am fat and that is bad, with the implied message that I'm a moral failure, or lazy, or a bad person because I am fat, which is what I suspect a lot of people truly believe. 

Nobody should have to feel that way when doing something as normal as going to the doctor. Everybody, in every country, should feel empowered to present for care without judgment. 

This story has no ending, as I'm still waiting for my blood sugar results. I can't imagine I'll be told I'm fine. 

There is one happy conclusion, however: unlike so many doctors before her, the endocrinologist didn't say a word about my weight. I told her I'd had COVID about six months ago, and the symptoms began immediately after. I'd had my blood sugar checked before I got sick, and there was no issue. She pointed out that there is some evidence that COVID can actually cause diabetes in rare cases, so I was right to be spooked. She asked me if I had a family history of diabetes, which I do.

She did not exhort me to exercise or eat less. That's a good thing. There is no overweight person in the world who is unaware of it, who hasn't already been told this, who doesn't know. It's never new information. It's not helpful. 

She did her job: ordered the necessary blood tests and told me how to fast and eat before each one. We'll discuss the results next week. 

I only wish every other doctor in my life had approached it that way.

If I had to offer any general advice, it would be the same for Taiwan as for the US: stop. Just stop. Leave people alone. You don't know their lives, you don't know their health, and the "I'm just concerned about your health" concern trolling is actively harmful -- but you knew that. Treat health issues as health issues in and of themselves, and don't tie moral rectitude or assumptions about health to weight. Every single thing you want to say, everyone already knows, and it does not help. Listen to Maintenance Phase and just...stop. 

Pill popping nation? Yes, but also Overworked Nation

I've been taking time off blogging for a bit, because there's just too much going on in my life and I don't have energy to deal with it all and keep a blog. What's more, most of what I have to say is a big fat downer guaranteed to not help me win friends or influence anyone, so I'm waiting until I can say it more neutrally. 

Then I read Pill Popping Nation in the Taipei Times this morning, and felt like popping in -- pun very much intended -- with a quick reaction.

Even here, it's going to take me awhile to get to the point. Please bear with me; I'm writing this on the fly when I don't really have the time.

I'm a chronic insomniac, and have been for as long as I can remember. Some of my childhood memories include staring at red-blaring numbers (remember those clunky fake-wood alarm clocks from the '80s?) as they ticked past midnight on a school night, feeling my cat hop onto my bed as Mom's snores in the next room grew deeper, falling half asleep until I dreamed up black snakes under my pillow and jolted me awake, or lying there as the same six bars of some song I didn't even like played over and over in my head. 

Once, I wandered into the kitchen for some water and found Dad awake as well, typing away. I think we were still using real typewriters back then. Turns out staying up late to write runs in the family. 

I struggled through adolescence and early adulthood. I rarely excelled at office jobs because flextime wasn't popular in the early 2000s, and the usual 9am start time was deeply incompatible with my rebellious brain chemicals. The anxiety diagnosis came in my late 30s as I was wrapping up graduate school, the ADD diagnosis on its heels. It made sense; my solid academic work was churned out despite my study habits, not because of them.

Sleeping pills worked, and they were available in Taiwan. They were prescribed by a highly-recommended psychiatrist who did take the time to talk to me, so it didn't feel like I was reaching for an easy answer. Then pandemic travel eased slightly and I visited the US in May. Turns out my Dad and I are not the only ones in the family with these issues, and I was introduced to the magic of edibles and CBD tea.

Nothing has ever worked so well as those plant-based solutions. I was anxiety-free for a month. I took no pills. I slept like a child who'd snuck a few too many sips of her parents' drinks. I even wondered if it was New York City easing all my issues. But no -- the solution was herbal all along. And no, I do not mean Chinese medicine (which I've tried to no avail.)

What does any of this have to do with Han Cheung's excellent article?

Well, I know a thing or two about being up all night, most nights, to the point that it affects your concentration and work. I know about hanging out on the couch waiting for the Lendormin to kick in, because if I try to lie in bed all I'll get is a repetitive and unwanted brain concert, six bars for each song.

Frankly, I was surprised to learn that one in five Taiwanese people share the same issues. That number does indeed seem high.

Because I take sleeping pills, I know that the fundamental point of the piece is correct: Taiwan's National Health Insurance is fantastic -- I pay next to nothing for my tiny white solutions -- but it doesn't promote holistic care. My anxiety and insomnia are probably baked in, but if I wanted to figure out what else was going on, if anything, I'd probably have to take two weeks off to see a long list of doctors to have a look at everything from my heart to my ****. There would be no general practitioner guiding me or facilitating any of it.

Not that I'm complaining -- at least it would be affordable. In the US, I'd probably just suffer and get fired a lot because I can't sleep the way a 9-5 job demands, and probably still wouldn't be able to afford adequate medical care. Now, people actually think I'm good at work!

But there's more to the story of a nation of insomniacs than "you need holistic care, not pills". 

You know what this country is? Wonderful, but also overworked. Managers tend not to be particularly flexible; 9am is 9am even if they know you were working on that project until midnight, because they assigned it.

I've had accountants fall asleep in their English class because they were working 9am-2am for months straight. I know people who've gotten emails at three in the morning, and woken up to someone angry that they hadn't responded yet. Kids go to school at 7am and return from after-school school at 10pm. On the weekends they have expensive weekend school. How could one not expect those kids to grow up with severe sleep issues?

Regular business hours appear to be 9-8, or 8-10, or 7-11, or simply It Never Stops. Calling a meeting at 6pm, or handing someone an urgent assignment on Friday night (due Monday!) is so mundane that I can't even give you a specific example. They all glom together like a big goopy ball of exhaustion. 

I don't think office workers take 1pm naps because of some cultural thing. Although daytime naps can mess up a sleep cycle, I think they're common in Taiwan because everyone is overworked all the time. The napping starts in school because the kids are overworked, too.

You'd think exhaustion would help one sleep better, but it does the opposite. 

As for me, well, I'm freelance. I bring it on myself. I'm not tormented by bad managers. I like my work and I like money, so I say yes to everything and work out the scheduling later. But I can't deny what I see in everyone else: they signed up for a regular job and a salary, not to be tormented by garbage management after years of being tormented by taskmaster teachers handing out pointless busywork. 

Truly, I love Taiwan. And yes, holistic treatment matters in reducing dependency on sleeping pills. 

But the solution isn't "acupuncture", "relaxation methods" or "traditional Chinese medicine". 

Those things might help, though I'm not an enthusiastic supporter of TCM. 

The solution is two simple things that Taiwan is not even close to prepared to do:

The first is a comprehensive overhaul of work culture in Taiwan. Most managers probably know that they are terrible (maybe this is why they have trouble sleeping, too!) Society needs to come together to pressure them to be less so.

The second is to legalize medical marijuana, especially edibles (because smoking is bad for you, period.) At the very least, CBD needs to be made more available. It's a healthier, non-addictive alternative to Xanax and Ambien, which seem to be what most people take. In other words, the most effective herbal remedies are specifically the ones that aren't legal in Taiwan, but should be.

There's no acupuncture or breathing technique strong enough to fix the problem until we address not just the internal factors causing Taiwan's insomnia issue, but the external ones as well.

In quarantine, who can hear you scream?

My teeth are like these chairs

My teeth and I have a somewhat adversarial relationship. I just want teeth that work and don't disintegrate. If they stayed in my mouth and met that most basic criteria, they could be brushed twice a day with a sustainable toothbrush and fancy Italian toothpaste that gives one's breath a whiff of sweet jasmine. 

Sadly, it was not meant to be. I don't like my teeth, mostly because they don't like me. The devils just won't stop acting up. They develop problems at the worst possible times: in Singapore on vacation, while I have COVID, in the middle of proficiency test examining.

So, I just wanted to write a little about my experience in quarantine -- specifically, what happens if you develop a bit of a dental drama at a time when no one can help you.

It seems I've developed a severe toothache. This tooth has bothered me for awhile; I actually need an implant, but the dentist says to keep on keepin' on until there's no alternative. Implants are expensive and the procedure takes awhile to complete. That, and every time I think about a screw going into my jawbone I squirm and tear up and he sees it. I know it's not supposed to hurt, but tell my lizard brain that. 

This round of tooth pain is so unbearable that I am afraid to take more painkillers, as I've already reached the 24-hour hard limit. Ice helps but only briefly. I have numbing gel and clove oil and they do not work. I can barely eat and I'm sleeping poorly.

Knowing that they will let you out of quarantine for medical emergencies, I called 1922. They gave me the city government phone number, which I called this morning. 

The city government worker who answered said that the whole "emergency quarantine leave" thing is only for the actual emergency room. If there's one thing I know from my dental troubles, it's that emergency rooms do not include dental care unless you've been in, say, a major car accident and your face is messed up in a very urgent way. 

"Nobody's going to be able to treat you," she said, not unsympathetically. "The best they'll do is give you more pain medication."

You mean the pain medication I am quite literally in danger of overdosing on, which still doesn't work? 

Yep.

Even though I tested myself this morning and at the 10-minute mark stated by the testing procedures, it came up negative? (After another 15 minutes a faint T-line appeared; perhaps I am not as COVID-free as I'd thought when the timer went off). 

Yep.

I understood the minute she said permission to leave was only for emergency room services. Like in the US, the health system acts as though your teeth are somehow not part of your body -- any other pain might be an emergency but nobody will help you with your teeth. Taiwan's health insurance covers fillings and root canals, but not crowns or implants. Teeth, apparently, don't matter and tooth pain doesn't really count. 

I couldn't really be angry about this. Upset, unhappy and in pain? Sure. But "angry" isn't fair: if you were still under a government-mandated quarantine anywhere in the world, would a dentist see you? I mean, that's the kind of doctor you breathe on the most!

The only real differences between Taiwan and the US in this regard seem to be that Taiwan enforces quarantine a lot more strictly, and in Taiwan you can actually call someone to ask what your options are. If you're lucky, you might even get help in English -- I no longer need this, but there was a time when I did. I feel for newcomers who are now in the same position. I feel even more for the majority of foreigners whose native language isn't English, who may have even more difficulty accessing information and help. 

An American friend said it seemed unfair: if I wanted treatment it should be my right to break quarantine and seek it. I understand that perspective, but the Taiwanese perspective that I could cause the dentist to fall ill and potentially create an outbreak in a medical office made sense. Taiwan wasn't going to let me die of a brain infection, but I would potentially have to endure some pain for a few days longer than I'd like. 

I did not want that pain, but I understood the general principle. I'd also learned that naproxen, or a combination of ibuprofen and acetaminophen, were more effective than either ibuprofen or acetaminophen alone, that sucking on whole cloves worked better than the oil, and that if I iced it for longer I could calm the pain somewhat. It wouldn't be fun but it would be survivable. 

I made an appointment at a hospital for Wednesday morning, the minute I am out of quarantine. No private clinic would see me until 14 days after a positive test. I could make it until Wednesday, but not the week after. 

And then...a miracle. 

When I reported to Ren'ai Hospital that my tooth pain was severe enough that I wanted to see a specialist and could not easily wait, I thought the phone number they gave me was a dead end unless I actually developed sepsis. 

But no! A hospital staffer unexpectedly called me today to say they'd gotten a report of my situation and asked if I wanted to go to the emergency room. I said I would be willing to, but if a dentist wouldn't see me, what would be the point? 

So she looked around and found a dentist willing to do online consultation. It's not perfect -- dentistry really requires a better examination of one's teeth than a phone can provide -- but it's someone, willing to do something. She even added me on her own Line to help me set up the consultation with the dentist.

That all worked out (though the process was a little confusing). I still haven't figured out how to get pharmacies to deliver to my home, so a friend came by, picked up my NHI card and some money, ran it up to the dentist, got my drugs and ran them back, all without coming face-to-face with anyone in the House of Plague.

I don't know if it would have rolled out differently if I'd been anything other than a white woman. Would a local have gotten such help? (Would they have needed it, knowing the language and having better connections than I ever could?) How about a foreigner who wasn't obviously Western? I have no way of knowing, I can only relate the experience I had. 

Perhaps I was helped because I happened to go through Ren'ai Hospital, and someone there happened to take my issue seriously enough to step in. Would I have gotten care if I'd reported another way? I have no way of knowing. 

Honestly, this was better than anything I could have pulled off in the US (without lying about my COVID status there). I understand worry about putting your health in the hands of a big government system -- what if they prohibit the path that's best for you? Yet, I can't say that's what happened. Yes, Taiwan can force you to stay in quarantine and the US can't. But would anyone in the US have thought to call me up and get me what I need like that? Doubt it. I'd have been on my own.

This isn't to say I prefer all-powerful, paternalistic or authoritarian governments. I don't. I would not have gotten what I needed in most such governments. Could you imagine things working out this way in China? I can't. 

Rather, I prefer governments that at least make an effort, even two years into a pandemic. I know that's hard to do in larger countries like the US, but the US also has more resources. They could try to meet residents' needs while having stronger policies to fight COVID. They just...don't. Maybe it's a cultural thing -- I feel like in the US the service you'd get would be very much dependent on your ZIP code. But from here, it looks like giving up.

My experience didn't deliver a perfect solution, but now I have what I need to make it to an appointment. I'm still in pain but I hope it will start subsiding. I feel pressure in my tooth from swelling or (not to get too gross about it) pus. But I got necessary drugs, and I won't be putting any doctors at risk.

What to do if you get COVID as a foreigner in Taiwan

I don't have a relevant cover photo, so enjoy this pretty tile from Portugal.

Other than having "I've finally bagged me the 'rona!" stuck in my head for the past few days, I've been thinking about how to help other foreigners in Taiwan with the whole process of it all, once you've tested positive.

It's not particularly straightforward, even if your Mandarin is pretty strong, and most of the guidance online is inadequate. "Find a clinic or hospital near you for a telehealth appointment!" is not useful if you feel terrible and are not up to searching online to find one. "You can get medication delivered to your home!" is similarly unhelpful without clear directions as to how, especially if you're not feeling well and don't have the energy to figure it out on your own. 1922 varies depending on who's available to talk to you at any given time: one friend got immediate help, the other got asked her name and phone number in Mandarin and was told someone would call her (fine if your Mandarin is okay, not great if you don't speak it.) 

So, I thought I'd do my best to write a guide. This is specifically aimed at people whose Mandarin is worse than mine, who don't have, say, a local significant other to help. Mine's not perfect, but it exists -- if yours is better, you probably don't need my help! 

Before you test

I strongly recommend, before you even feel sick, to have a plan in place. I didn't -- unwisely kept putting it off as non-urgent -- and had to figure all this out while sick. Learn from my mistake! What sort of plan? Well, you'll want to: 

1.) Download the EUCare app and register, if you have National Health Insurance (you can't use it if you don't). The registration is offered in English, and it doesn't obligate you to make an appointment. You'll need to verify your phone number and possibly e-mail.

Be sure to enjoy the "Congratulations, you are now part of us!" message you get when your registration is successful! I had a little trouble registering, but when I swiped the app closed then re-opened it, it worked.

2.) Figure out where you'll do your telemedicine appointment in advance (which may or may not be through EUCare). If you plan to use the Taipei City Hospital system and don't have anyone to pay the registration fee for you, then you may want to download a relevant app such as Taipei Pass in advance, as they have to review your account before you can use it. 

3.) Have a plan in place for paying the registration fee and picking up any medicine -- this can be done through online payment and home delivery, or having a trusted person be able to take your health insurance card to the hospital or clinic and pick it up for you. I strongly recommend discussing/agreeing in advance with those close to you regarding who will help whom if you suddenly can't leave the house. Even if you have a partner, they may get sick too. It is so much easier to have someone you can call at the ready to go pick up what you need.

4.) Keep a supply of painkillers, cough medicine and diarrhea medicine at home (just trust me on that last one). Some of those flu drink packets don't hurt, either. I also recommend having some citrus or sour candy or lemon drink mix on hand if you think you might be taking Paxlovid. 

Other items my friends or I have felt useful to already have at home:

Extra pet food, if you have pets (have a plan if you have a dog who needs to go out); extra garbage bags; sufficient toilet paper; lip balm, toothpaste and lotion; seasonings to make your food appetizing; and a stash of something you like that's not perishable so you don't need to immediately order grocery delivery -- for me that's frozen dumplings but it can be anything you can survive on for a day or two. 

5.) Figure out in advance if you qualify for Paxlovid (here's an FDA guide from the US and another guide regarding what Paxlovid is and who should take it). In Taiwan, I don't know every regulation, but chronic issues such as asthma or high BI qualify you, among others. There are also risk factors (such as liver or kidney issues and certain contraindicated drugs). I'm not a doctor; if you think you qualify, be ready to ask at your appointment. They may not ask you; you'll need to bring it up. 

Not everyone needs Paxlovid, so don't ask for doses you don't actually need. I qualified and received it, Brendan didn't, and he's doing fine. If you do need it, however, be prepared.

6.) Have some idea how you will get food delivery, especially if you have, say, a fobbed elevator and delivery people cannot get to your door. This may mean talking to your doorperson, making arrangements with friends or stocking up in advance on non-perishables.

Testing positive

You no longer need a PCR confirmation; an at-home rapid test is sufficient. You will need your health insurance card, positive test result, and a pen/marker. 

Now you'll need a confirmation appointment. You can do this in person, but you can't take public transportation, so if you don't have a vehicle (or are too sick to drive) and there's no one to take you, you'll have to walk. 

I strongly recommend that you do this online instead. 

Using EUCare

You can do so through the EUCare app. I'll link to some other resources after the screenshots below.

Once you register, there is a button for making an online appointment -- it's the "Rapid Test Positive Confirmation" button with the bell. 

They only have one clinic (located in Tainan) that does confirmations all day, so if you can't find anything near you, select "Tainan": 

The other options to the right are, in order: Taipei City, New Taipei, Taoyuan, Taichung, Tainan, Yilan, Hualien and Taitung. 

I don't know why it doesn't include every county, but this is an online confirmation, so it doesn't really matter. 

If you've selected Tainan because it's the only one open, choose Chimei, the first option:

I can't promise you'll only be given this option, so if there are several, choose this one: 

Choose a doctor and time (this is just one option, from what was available when a friend tested positive):

You may be asked to upload a picture of your health insurance card and positive result, and you may also be asked if there's anything else the doctor should know. You can type this in English. 

If the system acts up, just close the app and try again. It's a little buggy but it usually works at least on the second try. If you choose an option other than Tainan Chimei, and can't read what the choices are, I recommend getting Google's Translate app, which allows you to upload photos, including screenshots, to tell you what they say. 

If you don't get those options when you register, contact them via Line (the Help icon at the bottom -- make sure you have Line installed as it will take you over there.)  

Or just sign out and in again: pink button to sign out, yellow to get back in, and the circled option once you do that.

You can also use the Help function other issues with the app, and if you tell them in the beginning you prefer English they'll do their best (I didn't use EUCare but a friend did, and this is what he told me.) When you add their Line you'll get a bunch of messages -- these just tell you that the Help service is for using the EUCare platform, not actual medical attention, a rapid test confirmation or a COVID taxi, and that it's illegal to insult or abuse them or send pornography. 

You'll get a notification when it's time to join. Just open the app and press the button.

The doctor you get should be able to speak English (most doctors in Taiwan do, even if service or support staff do not). If you have any concerns such as picking up medicine you can ask at this time. Have your address ready -- if your confirmation appointment is not close to you, they can send any medicine to a nearby pharmacy.

According to another friend this can get difficult if you don't speak Mandarin -- if you don't, it's best to have someone who does on hand to help you. You'll have to choose the pharmacy and then have someone pick it up for you, or call to have it delivered. 

However, there doesn't appear to be a charge to use EUCare -- at least, my friend wasn't asked for any money.

Taipei City Hospital (for Taipei residents)

If you live in Taipei City, you can make an appointment through the city hospital system. This is what I used. The page tells you about how to do this -- I checked it in Translate mode for you all, and I can confirm it's pretty readable. You'll need the same items as above: National Health Insurance card (if you have one -- if you don't, have a photo ID ready), positive test and a marker. Click on one of the options in green: 



The options, in order are:

Chunghsiao/Zhongxiao (near MRT Houshanpi)
Ren'ai (at Ren'ai-Da'an intersection, near Zhongxiao Fuxing)
Chunghsing/Zhongxing (near Dihua Street)
Heping (near Longshan Temple)

Women's and Children's (on Nanhai Road near Freedom Square)

Choose whatever is most convenient for you and -- hopefully -- the person you have lined up to pick up your medicine and pay your fee. Actually inputting the information is not very hard: 



Choose a date (usually the same day or next day). 上午 is the morning clinic, 下午 is afternoon. It asks for your full name, date of birth, ARC number, phone number and address as well as a captcha. I put in my address in Mandarin, so I don't know if it will accept English. If you're worried about this, have your address in Mandarin ready to copy and paste. These are just examples of choices if you click "Ren'ai".

Click the blue button at the bottom to get your number. Then add the relevant Line ID and change your account display name.

You'll also need a method of payment for the NT50 registration fee if nobody can go to the relevant hospital for you. You'll need to download one of the the relevant apps such as Taipei Pass or the city hospital app (the latter in Chinese, for you to copy and paste: 臺北市立聯合醫院行動掛號). 

Taipei Pass takes awhile to activate as they have to review your registration. The city hospital app is only in Mandarin, and even though I can read everything on it, I can't figure out how to register. So, I strongly recommend you have an agreement with someone in advance. 

I used Ren'ai. I was asked to add the relevant Line ID and change my display name to my name and appointment number (an example is given on the information page.) They sent a message a few minutes before with a link, which I clicked on. A button appeared to enter the conference room and I did. The appointment was efficient, professional and in English. I didn't see that they actually used Line at all!

My husband was asked to add a different Line account when he tested positive (yes, we are a COVID House now) -- mine was tpechra9, his was tpechra8. His appointment actually was through Line, so just stay by your phone and wait for a notification. Have a picture of your ID/NHI card and positive test ready. I was asked to show mine -- all the appointments are recorded -- but he was asked for a photo upload. 

There are specific pickup windows for medicine, which is handled outside the main hospital. Ask your doctor which window your pickup buddy will need. If you need it delivered, ask at this time. I am not sure how to actually do this, as we had someone pick it up for us both times (Brendan did mine, and a friend did Brendan's). 

If you think you qualify for Paxlovid, be sure to proactively ask about it. It does not cost extra.

Local Clinics

You can also confirm your positive result through a local clinic. However, when I attempted to find one, I found that feeling like absolute garbage did not improve my ability to find that information and make phone calls in Mandarin. Turns out, being barely able to sit upright makes it difficult to do something in a foreign language. Who would've thought!

If you do want to go this route, here is a page listing all clinics which do positive result confirmation so you don't have to root around on Google Maps, like I tried to do. Again, learn from my mistakes!

Each link will take you to a city government page with some PDF links. These are all in Chinese but they translate to English fairly well (again, I checked for you). The PDFs are what contain the actual clinic and hospital contact information; you have to call yourself. 

In Taipei, the city hospital system is certainly easier to deal with, but this may be of help if you are outside Taipei. It doesn't translate well, as the links disappear. If you don't have even a little Mandarin, I recommend you at least be able to recognize the characters for where you live if you want to use this method.

Lienchiang (Matsu) and Kinmen just list the clinics with no links -- it's up to you to look them up and call them. No, they probably don't speak English, so if that's a problem you'll want to stick with EUCare.

Keep in mind that while the doctors usually speak English, the staff often don't. If you feel comfortable calling around while you are sick, then you probably didn't need my help in the first place! However, I wanted to include this option.

After confirmation

The confirmed case form

Soon after you are a confirmed case, you'll receive a text message with a link to a form which is helpfully all in Mandarin. Unfortunately, I had not thought to write this post when I received it, so I filled it out and sent it off without taking screenshots. 

If you can read Mandarin, it won't be that hard (though the information for close contacts -- that's family and workplaces only -- can get a bit lengthy. It's not required, but if you do have close contacts who aren't aware that you're positive you do need to fill it out.) 

If you don't, my best recommendation is to take screenshots and open them in the Translate app. Some difficult sections, such as asking you your neighborhood or 里, are actually optional. I happen to know my li but not every foreigner does, and it's a pain to look up.

Soon after, you'll receive a bilingual notification of quarantine, which will tell you what day you can leave home. This should be sent to you by text, with the last six numbers of your ID as the password. The link does expire after a few days, so I suggest you download this. I had to email it to myself and open it on my desktop to do so. 

The phone calls

You should receive two phone calls on your first official day: one from your district health office and one from whoever is designated with checking on you for the national government (for me, someone from Ren'ai Hospital calls daily). At least, that's true for me -- Brendan says he didn't get a call today, but I did. 

The district health office is your friend -- if you need help with something like garbage service, tell them so. If you're unsure, take down their number. You can always call them later to ask for help, as they'll only call you once. 

Depending on where you are, the district health office may not speak English. I don't know what to tell you except to be ready for this. 

The daily call checks on your symptoms for the national database. I usually talk to them in Mandarin, and you get all types. The first one confidently spoke English before I even tried to break out my language skills. The next day, the caller offered, but seemed happy she didn't need to. The third caller was clearly terrified of talking to a foreigner at all, even though I assured her she didn't need to use English. So, you know, you get all kinds.

If you don't speak Mandarin and make it clear in the beginning that you need English, they may make sure someone who speaks it will call you daily, or transfer you. I can't promise that, but that's how these things usually shake out. 

I'm quarantined but need to see a doctor for something else!

If you get sick with some other thing while in quarantine, you can make an appointment through EUCare (go to the button that says "Specialist" and choose from the options (it will again be a list of hospitals and clinics by location in the same order as above). In Taipei your best option is Mackay (台北馬偕紀念醫院), which is second on the list if you click "臺北". Choose your preferred clinic by the photos -- for example, for persistent cough, click on the lungs. Choose the last one, Family Medicine, if you're unsure what you need.  Input your information and a photo of your NHI card, and specify what you need in the box. You can do this in English. Then book the appointment and wait for the notification. 

The only part that may be confusing is the "Unified ID" (統一編號). That's usually a term for a business ID, but it's used here. Input your regular ARC/APRC ID number. 

You can also call 1922 for help, though their ability to do much will depend on who's staffing it at that time. Some people I know have gotten excellent service, some have gotten a gruff request for a phone number in Mandarin, so someone could call them back in English. 

I personally have developed a toothache in quarantine, and will probably call 1922 about it tomorrow, so I'll update with any useful information (there is no dental icon on EUCare). 


Other advice

These are just some tips I have from being in quarantine. 

First, I cannot stress enough to prepare in advance. I had done some of the not-yet-positive things I suggested above, but not all of them. Be smarter than me. Agreeing in advance with multiple friends that you'll all help each other will especially make everything so much easier. 

Secondly, if you do get Paxlovid and develop Paxlovid Mouth, the secret to killing that awful taste long enough to eat is citrus. It could be lemonade, lemon water, sour candies, Vitamin C tablets (the kind that come in the yellow and green tube, or the Korean ones in the moon-shaped plastic dispenser work great.) It could even be Pocari Sweat, which is mildly citrusy. But you'll want something -- eat a sour candy or drink lemon water if the taste becomes unbearable or you want to eat a meal that doesn't remind you of battery acid upchuck. It kind of tastes like a bitter chemical sewage; I really cannot emphasize enough how awful it is. 

But lemon and citrus kill it! It's kind of the big secret to surviving those five days while eating somewhat normally. Stock up. 

Drink massive amounts of water. We're talking as much as you can take. Be ready to pee it all out, but just keep drinking. 

Brendan says coffee every morning helps his symptoms. I drink it too, but haven't noticed that it makes them much better. It's worth trying, however. 

Rest even if you feel okay, at least for the first few days. Use this as an excuse to do nothing. 

There is no need to test daily. You can't leave for a week anyway, so it's not worth testing until you're close to your quarantine end date. Save your tests!

If you've read this far, there's a fair chance you're sick. If not, stay healthy!

What it's like getting vaccinated the day after the community transmission scare

Two weeks ago, we made the decision to sign up for self-paid AstraZeneca vaccines in Taiwan. We'd held off in the beginning, figuring that would give everyone with a more urgent need than us time to sign up. Although we have good reasons -- most of our close relatives in the US are over 70, so flexibility to return for family reasons matters -- we felt that there would surely be others with more urgent travel needs than ours. 

The government had also made it clear that you needed a "reason" to get the vaccine, stated orally or on a form, before getting the self-paid option.

Soon, however, we started hearing reports of the opposite problem: lots of AZ doses and not enough people signing up for them: there was a fear that many doses would expire before they could be used.

Anecdotally, it seemed people didn't want the AZ vaccine when seemingly more "effective" (or at least more popular) options such as Moderna and Pfizer are going to be available soon. With low coronavirus risk in Taiwan, it felt to many that they had the luxury of waiting. 

We decided at that point to go for AZ. That we were not stepping on anyone's toes, a real travel need, and the looming prospect of long waits for more "popular" vaccines all informed our choice. Plus, this informative video linked by Kerim Friedman dispels myths that it's worth waiting for a "better" vaccine: all are good at preventing serious coronavirus symptoms, the kind that kill you. The best shot is the one you can get, and my main aim here is to not die.

By the way, you can try to sign up at any of the hospitals linked here. It doesn't need to be in your city. I recommend choosing your hospital carefully -- perhaps be willing to go out of your way, though how far you want to travel when community transmission is a reality is up to you -- and trying at exactly midnight, when the system refreshes. 

I've heard some reports of hospitals who refresh their appointments at 9pm, so that's another time to try.

People are saying women who have taken oral contraceptives in the last 28 days are currently being turned away. The forms they give you say it's "not recommended", but only mention oral contraception. In theory, if you have an IUD or some other form of contraception, you should be fine. Be aware, however, that there are healthcare professionals in Taiwan who don't necessarily understand that there is a difference. 

Anyway, all of that was two weeks ago, when appointments were still fairly easy to get. 

In the meantime, many of our friends got vaccinated, and reported short wait times, staff that was not overly rushed, being asked for reasons but not pressured for proof of intent to travel. It seemed very much like a "no big deal" situation.

Then Tuesday happened, and Wednesday after that.  Community transmission was announced in Taiwan, and yesterday there was discussion of entering Level 3 restrictions due to a record-setting number of new infections. Level 3 is fairly close to lockdown (we are currently at Level 2). As there is community transmission in my neighborhood which made the news, if this happens we are likely to be restricted from leaving the immediate area. Heath Minister Chen Shih-chung's repetition that this was "critical" and "not a joke" has elicited anxiety and a sense that we need to keep fighting.

I had never been more overjoyed that I'd booked my appointment two weeks ago! I felt lucky to have an appointment at National Taiwan University Hospital, because it's not particularly far from my home. 

So here was what it was like: 

Forget everything you've heard about there not being crowds. It was packed. The healthcare professionals making it all run smoothly were absolute heroes. People seemed nervous, and you could tell the recent announcements were having an effect. 

This is entirely rational, of course. A week ago everyone thought they had the luxury of waiting, so many chose to wait. Many weren't even sure they could get a self-paid vaccine, as they didn't have a "reason". Now, the situation is more serious and people are changing their thinking accordingly. They'll take the vaccine they can get. This is smart, as I keep hearing that once other options arrive, one will not be able to choose which vaccine they receive: this is a public health drive, not a hat boutique. 

And it makes sense that now more than ever, any pretense of needing a "reason" to get vaccinated no longer matters. What Taiwan needs is shots in arms, as fast as possible, before things can get truly serious. Your vaccine is not selfish; you're helping to control the potential spread. 

I showed up at the main entrance of NTUH, and the workers checking everyone's ID there directed me to an information desk, where a friendly volunteer led me to the vaccination area. Once there, someone at the front will give you the forms you need, and there are English speakers who can tell you what to do (I'm perfectly capable of doing all of this in Mandarin but it was easier to just let it happen in whatever language the workers chose.) 

You are given a number which is not the same as your registration number -- that's only for making it easier to identify registered individuals. I was happy I printed out my online registration as it made finding my registration easy. Then they take your blood pressure and temperature. Mine was a bit high because I was, well, nervous! You have to sign a few things, but they mostly fill out the forms for you. You do have to check that you "agree" to receive the vaccine and sign that part.

Then you're asked to take a seat, and you just wait. They call people in groups of 5 or so, and it took about an hour and a half for my number to come up. 

I was led into a comfortable seating area with my 'cohort' (the five people whose numbers were called with mine). A friendly Italian man who seemed to be a senior citizen said he had not registered online; he'd just shown up after reading the news and was able to get a spot! I have no idea if it actually does work that way or he was an exception, or you can do that if you're over a certain age. I'm not judging him, of course -- in his shoes, I would have done the same.

At no point was I asked about my "reason" for getting the vaccine, despite my having one! I don't know if this is an NTUH thing or, with new community transmission announcements, perhaps hospitals are dropping the pretense of requiring a reason they would never follow up on. All I can say is that for NTUH, it seems to be shots in arms, no questions asked. Get one if you can. 

Of course, I'm an obvious foreigner. It's possible they didn't ask me because foreigners are assumed to have reasons to travel. I don't know what they asked locals, and I only saw 3-4 other foreigners among hundreds of people waiting. 

The actual procedure first takes you into one room where they scan your NHI card and prepare your yellow "vaccine passport". You're handed an appointment date and number for the next shot in eight weeks so you don't have to sign up on your own, and an information sheet (English is available) for what to expect after getting vaccinated (all the usual symptoms, and they tell you to drink a lot of water).

Then you're taken into the next room where it's all business: they sit you down and the shot goes in. I think they asked me to sit still, but honestly it happened so fast that I don't remember.

Then I was up and out, and the next person was getting their shot before I'd even reached the register. 

Obviously, it would be this way. Who could expect different? But after a year-plus of coronavirus horror stories, the dramatic rollout of vaccines, the race to contain the virus before it can mutate again -- it has all been very cinematic (not in a good way). With all that high-stakes drama, I suppose the final stage, where you step in and finally get the vaccine turns more ceremonial in one's brain. But of course, there was never going to be a symphonic accompaniment. 

It's just a shot. It hurts a little. Most shots do. 

Because the power plant malfunction happened just before I got the shot, the hospital computer system wasn't working well. But, of course, being a hospital they did not lose power. To keep everyone moving, I paid my NT$600 and agreed to receive a receipt later, once they got the right systems running again. 

To ensure that you stay for 30 minutes after getting vaccinated, they don't give you your 'yellow book' immediately. 30 minutes later they'll call your name and hand you your book. Someone brought me a receipt for my payment, as well. 

Once you have the book, you can go! Just remember to bring your yellow book, NHI card and appointment sheet on the date you are given. 

It's been a few hours now and I feel fine. I thought at first that my arm was a bit sore, but it doesn't hurt now. I feel perhaps a bit fatigued, and I bet you anything my prose is wooden and I'll cringe at this post later. I'm drinking lots of water and planning to take tomorrow off. My husband is getting his shot tomorrow; hopefully if we both experience after-effects it will be a day apart and we'll be able to take care of each other. 

It's also a psychological burden lifted. There's still worry for the country and the world, but it helps a little to ease personal stress. I know one shot doesn't confer sufficient immunity, but the news this week had me on edge. I hadn't turned to anti-anxiety medication in months but found myself taking it these past few days. Knowing that I still have to take all the usual precautions but I'm on a path to immunity has helped me calm down. 

Update: I felt more tired than usual after dinner and draining my water bottle. I refilled it and went to bed, only to wake up around 4am with aches, cold-like symptoms (something weird going on in the area behind my nose and mouth) and a headache. No fever, if anything I wanted the room cooler. I took some ibuprofen, rubbed on some Tiger Balm and drank down my water bottle again and managed to fall asleep for a few more hours. 

I woke up with a sore arm, fatigue and another headache. I took more medicine and have been resting. Ice packs help. It feels more or less like a hangover, and not as severe as I expected.