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.

Why stay in Taiwan?

It's the little things...or is it?

You probably don’t care about my life, but here’s the deal. I’ve had a somewhat tumultuous week professionally, although nothing that ended up being terribly deleterious. I don’t want to say too much about it, but I’ve been feeling frustrated about the limitations of teacher training opportunities in Taiwan for residents like me, despite how much we can help in the face of Taiwan’s push for internationalization. 

I have no desire to discuss the details behind this; it’s insider beef that you really don’t need, and might be wrong of me (or at least harmful to me) to divulge. 

I've also been feeling more frustrated than usual about Taiwan's naturalization laws. Nothing has changed since the 2007 reforms, opening up a pathway for magical stardusted special and senior foreign professionals, basically saying most foreigners who call Taiwan home -- whether they're white collar like me or blue collar like most immigrants here -- are garbage. Not worth caring about. 

Yes, the road to dual nationality may be narrow now, but there's room for it to expand. But I fear it will happen when I'm too old for it to matter. I'm not sure exactly how I will grow old in Taiwan as planned, because I can't get a mortgage and don't have local family, but landlords don't like to rent to the elderly. What am I supposed to do when I'm 80? If the law changes when I'm 60, that's a little too late to fix the problem. 

There's something to be said for fighting for something so that the next generation can enjoy fairer access. And yet, recently I've been wondering if this is enough. Wondering why I bother. 

With all this in the background, I’ve been trying to blog about politics to get my mind off it. Nothing comes out right, though. I have a few half-finished posts that I might wrap up and publish anyway, or perhaps not. We’ll see. Maybe I just need to not with the politics right now. 

Instead, I thought I'd examine something else. I know perfectly well that I'm not actually going to leave Taiwan (which, to be honest, is part of the problem. Maybe I should be more open to doing so). So rather than stewing in my own angry juices over this, perhaps I should talk a bit about why I stay. 

People love to ask why I moved to Taiwan. That story isn't very interesting. Studying in India made me want to learn more about Asia in general. I spent a year in China and didn't love it. And yet, I still felt there was a lot for me to learn, and I like the general feel and pace of life in large Asian cities. So, I came to Taipei mostly out of curiosity. I certainly didn't know much about it. 

Why I stay, though? Maybe that's worth discussing. I've been here for 18 years now. The pay isn't that good. Career opportunities are middling at best. I do have a fantastic local network, but most of my close family live on the other side of the world. Nobody loves Taipei's weather. My apartment is nice, but apartments in Taiwan generally aren't. There's the ever-looming China threat (though I imitate local residents in living my life as though that's not a thing). 

And yet here I am. Still. I've been thinking about this for awhile -- it's easy to rattle off reasons to leave. Any article about the "ghost island" can do that. The more fruitful area to examine is why I stay.

I've identified five very generalized reasons why, despite its faults, Taiwan is the country I chose to call home. These are five things that I think are important for any country I might live in long-term, and Taiwan happens to excel at them.

For my own reflection as much as yours, here they are: 

1.) Generally good infrastructure, including (most especially) public transit

Not all of Taiwan has good public transportation, but Taipei does, and it's fairly easy to get to any other town you might want to visit. Getting around that town might be a challenge, but you can always get there. I live in Taipei, though, and this city has some of the best public transit in the world. In general, I appreciate infrastructure that works. That includes buses that run on time, a clean metro system, convenient trains.

Compare that to the US, where the only city that has public transit that comes close to meeting my standards is New York. That also happens to be a city where I couldn't possibly afford to live. I tried living in Washington DC for seven years without a car. People say transit there is good. I say it's a nightmare. 

Still, assuming I'd never move back to the US, I could enjoy good public transit in Japan, South Korea, Hong Kong, Singapore. If we're talking inter-city, even Vietnam. Europe, too, but there aren't really good jobs for me there. China, generally, has reasonable public transit. What could knock some of those countries off the list?

2.) An open and democratic government

Well, there goes Singapore, Vietnam and Hong Kong. China is an obvious no-go. I once considered moving to IstanbuI, but I can't get past the importance of a reasonable system of government. I might not have the right to vote, but it's important to me that my local friends do; I would find it very hard to exist as an admittedly privileged American in a country where I could send my ballot back every few years, but locals I knew wouldn't have access to human rights that I consider fundamental. 

For myself, well, I like to opinionate. It's important to me to live in a country where I can do so without fear of government retribution.

Beyond that, there's just something depressing about living in an unfree society. You may or may not have access to good journalism. Random bullshit things may be banned. Your friends can't say what they really think; you may not even know what they really think, depending on how severe the repression is. 

Being in Taiwan for two -- soon to be three -- presidential handovers, countless protests, a legislative occupation, and all manner of public debates? That may seem unimportant or ineffable to some, but it matters to me. Taiwan's democratic society is a big draw. 

South Korea and Japan are democracies too, though. Why not move to one of those?

3.) An acceptable level of gender equality

I'm not saying Taiwan doesn't have sexism and misogyny. Of course it does. The gender pay gap is still above 15%. But, compared to the rest of Asia, I daresay it's doing fairly well. 

Brendan has told me stories about Korea, where he would see job ads that openly offered men and women disparate pay for the same work. 

I know someone in Japan who once detailed many little ways in which women face discrimination; she once saw a pregnant woman stand up on the train for a salaryman! Discussing why that would happen, locals told her that the pregnant woman has an easier, more restful life while the salaryman is tired from hard work, so of course he should get the seat. I don't know that this happens frequently in Japan, but that it happened at all tells me that it may be a fine country to visit, but it's not a place where I think I'd be very happy living. 

Everything from work culture to beauty standards feels so much harsher in those countries. The fact that women make up such a small percentage of the workforce in Japan and are deeply underrepresented in politics are other strikes against it. I'll take the country that elected a woman twice, thanks. 

Korea is similar; the gender wage gap there is astounding (Japan is almost as bad). I've enjoyed visiting both countries. As a woman, I want to live somewhere with more equality. 

That brings me to my next point. 

4.) A high level of public safety

It's not just pay, work, politics and beauty standards. All three countries have very high levels of public safety, including for women. As an American, this matters to me. It wasn't fun growing up in a country where it wasn't safe to be outside alone at night. But Taiwan manages the high public safety with a whole lot less of the ridiculous discrimination.

This matters not just for me, but for my LGBTQ+ friends. South Korea, for instance, is not a very safe place for many people dear to me. Public safety isn't just about whether or not you're likely to get mugged or pick-pocketed. It is also deeply related to who you are. I wouldn't want to live in a country where I might be targeted because I'm a woman, or where my friends might be targeted for being gay, nonbinary or trans. 

This, of course, knocks many countries off the list -- including the United States. 

I considered adding "a high level of overall development" to this list, because so many of my points are oriented around that. Advanced economies are more likely to have good public transit and safety, higher levels of gender equality and functional democratic governments. 

But not always -- the United States fails on most of these counts. Plenty of countries that aren't rich do have democratic governments. Besides, I don't think anyone wants a middle class white lady to prattle on about how she wants to live in an advanced economy. In fact, it's not actually one of the key criteria.

Instead, my fifth point is more specific but is still related to overall development markers. 

5.) National! Health! Insurance!

As an American, I cannot express how much this matters to me. I spent the first half of my twenties kinda miserable because I needed to see some doctors, but couldn't afford any of them. My lack of access to affordable health care in the US is directly responsible for the back surgery I needed during my first year in Taiwan. 

This really matters! Health insurance alone is enough to make me forsake the US forever. 

That said, this point has been bugging me recently, because I'm in the middle of a tooth implant that isn't covered by Taiwan's NHI. All told, it will cost me about NT$87,000. The dentist has been clear that for me, it's a necessity (another one of my crowns is in danger if I don't get a tooth put in next to it). And yet, it's entirely out of pocket. 

I think NHI should cover it. After all, it's an absolute necessity for me unless I want to literally be toothless in a few years. 

But, all of that aside, I'm grateful that the many times I've needed to see a doctor in this country, that I could actually afford to do so. 

I'm still not feeling entirely all right about the state of my life in Taiwan these days. It hurts to want to commit to a place, without seeing a clear future there, especially in old age.

There is another reason I stay, but it's intensely personal: I truly believe in what Taiwan stands for. To me, Taiwan means standing up to a dictatorship that landed on your soil and tried to force you to submit, turning the country instead into a functioning and peaceful democracy. It means refusing to shatter under the constant threats from yet another dictatorship that wants to annex you by any means necessary. It means building one of the more advanced and liberal societies in Asia -- if not the most liberal -- on the back of a tragic and bitter history of colonialism and oppression.

That, to me, is worth fighting for. It's worth staying for. It's not on the list because it's not a specific thing Taiwan has, it's more of a narrative that Taiwan embodies.

It does help, however, to think through the reasons why I've stayed, and run through the possibilities of other countries where I might relocate. None quite hit the five criteria -- gender equality, health insurance, democracy, public transit and public safety -- that Taiwan does. Most countries can be exciting, interesting, historically noteworthy, or absolutely lovely. 

But I can't think of another one that actually meets these five benchmarks, all of which are crucial to me. Can you?

Pear-shaped

Something about this sculpture from Thailand being just a few body parts feels apropos

Content note: this post contains some descriptions of a health issue and its treatment. If such things make you uneasy, you may not want to read ahead. 

“In Taiwan this would have been resolved by now,” I huffed. “Fixed in less than a day. Ouch…ew!”

Brendan mumbled in agreement but did not look; only parents of sick young children and trained medical professionals should have to witness the drama playing out on my right thumb. We were in Portland, Oregon, at the dining room table of our friend’s mother-in-law, and I was doing some very gross things with my miniature medical mis-en-place. 

During the Las Vegas segment of our Great West Coast Tour (to New Englanders like us, Vegas counts as “West Coast”) I developed what appeared to be a mild case of paronychia. An infection around the nail. By the day of my brother-in-law’s wedding it was clearly not resolving itself. I bandaged it for our trip to the Grand Canyon because it hurt to touch anything without warning. 

When we reached Portland, the side of my thumb had puffed from pink to a furious red. My basic travel medical kit didn’t have the means to deal with this; I needed antibiotics.

“I just really don’t want to deal with the American medical system,” I said, even though we had travel medical insurance. 

We flew to Portland to visit old college friends. Someone produced Epsom salts; I submerged my thumb as Brendan cut up a dinner salad, my friends and I complained about politics and we all kept an eye on the kids. 

When I lifted my thumb out of the hot Epsom mug, my thumb had puffed up to sci-fi proportions. My finger had quite literally gone pear-shaped. A little white bulb of pus had gathered under the skin next to the nail.

My friend’s recommended urgent care clinic didn’t seem to be covered by our travel insurance. I called the insurer for a recommendation and was given a code to use for another one; it didn’t work. The provider tried to help, but ultimately sent us back to the insurance company, who confirmed that it never actually works and we’d have to pay out of pocket and submit a claim. We weren’t looking at huge sums of money, but I didn’t really want to submit something after the fact when it might get rejected. We tried another in-network provider and set up an online appointment for the next day, but then once again found that they couldn’t actually locate our provider information. At that point I was desperate — I could barely type. 

The whole affair took an entire evening, just to find a provider and make an appointment.  

The online consultation was fairly straightforward: I clearly had a paronychia, and I needed antibiotics. The nurse practitioner prescribed some and recommended I either come in to have it lanced, or I do it myself at home. 

“What does it cost to come in?” I asked. 

“It starts at $99,” she said. On top of the hundred bucks I paid for the consultation. 

 

That’s how I found myself at a dining room table laying out alcohol wipes, cotton pads and needles on a bed of tissues. I sterilized a needle and gently lanced the white bit. It didn’t hurt, which was probably a bad sign. 

The pus came out in fat yellow drops, staining the cotton pads a freaky green color. The pharmacy wouldn’t open until 11am, giving me plenty of time to relieve as much pressure as possible on my poor pear-shaped thumb. The result felt weirdly hollow, like a drained blister, but deeper under the skin. 

With our friend’s husband working the next day, we couldn’t fit into her car with the two children’s car seats. So we took an Uber to CVS while she drove the kids to a nearby cafe with big couches, with plans to meet there once I’d procured the antibiotics. 

Total time spent: six days from when I would have seen a doctor in Taiwan to when I actually saw one in the US. As I write this, the infection has not completely cleared; I feel like I have a shrinking cystic zit under my thumb pad. 

Total money spent: $140 US dollars, including the online consultation, two Uber rides and antibiotics. That’s on top of an insurance premium for three weeks of coverage that cost four times what we pay in Taiwan each month for National Health Insurance, and their actually covering it is not yet assured. 

Here’s how it would have gone in Taiwan: the same day I realized the infection wasn’t resolving itself as expected, I would have likely seen a doctor within walking distance or a short ride away on public transportation. In a hurry, I might have taken taxis for a total of about US$10. I would have immediately been given antibiotics and the doctor likely would have done a better job lancing it than I had. 

There would have been no question of National Health Insurance covering it. That’s why it exists. The appointment and the antibiotics would have cost about US$5. 

In the US we were lucky to be staying with friends for most of our trip (which is, of course, how we could afford it). We thus had immediate access to basic medical supplies. However, there should have been no need to wait that long to decide medical attention was necessary — letting the infection get a little out of control — spend that much time finding a provider, spend that much money and then lance it myself. 

In Taiwan it would have been a non-issue.

The mundanity of all this is the point: I’m telling you this gross little story exactly because it’s so banal. My only personal experience with the American medical system in 18 years was, in fact, not terrible. I needed medical care and got it, and the cost was something I could afford. That’s frankly unusual, and I was extremely lucky. 

But here’s the thing — even a not-terrible, incredibly boring (yet pus-filled) outcome was still worse in the US than it would have been in Taiwan. It’s easy to point to medical horror stories in the US and compare them to the rest of the developed world: impossible bills, long emergency room waits, avoiding ambulances because you can’t afford them, drugs you break the bank to pay for, long appointment lead times. 

Comparing a fairly good US outcome to Taiwan and still seeing the US come up short? I think that says something. Even when the American medical system basically works, it can’t compete with a small island nation that only recently developed and democratized. You don’t need a horror story to prove this. What is so thoroughly wrong with the US that it can’t even treat a simple paronychia without undue expense and stress?

We were ultimately charged for the consultation, and now have to figure out whatever complicated procedure is required to submit a claim, which may or may not be rejected. 

This should not happen, and in Taiwan it would not happen.

The US delivered a thoroughly acceptable treatment for my messed-up hand, and it was still more expensive, time-consuming and complicated than the same thing would have been in Taiwan. Frankly, that looks really bad for the US. 

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!