"Free clinic" means that there is no charge for medical service. However, with the implementation of national health insurance, the fees are not a major problem for visiting doctors anymore. Instead, the availability and quality of medical service have become the major issue, especially for people who live on offshore islands or in remote mountain areas but pay the same medical premiums. These people deserve equal medical care. Unfortunately, medical resources are still not allocated equally, so many hospitals still have to carry out medical care by travelling to these far-away locations.

MEDICAL CARE IN REMOTE AREAS

By Chen Chiu-shan and Ho Chen-ching
Translated by Lin Sen-shou

We all need to visit the doctor sometimes, but the unequal distribution of medical resources between city and country obstructs the commitment of the government to guarantee access to national health insurance for all people.

People living in cities do not need to worry about the availability of medical care, but what can people in remote areas do if they cannot find a doctor nearby when they need one?

Same Premium, Different Care

"There are eight villages in this area, but there is only one public health clinic. And it takes us three hours to go down the mountain to see a doctor!" An aboriginal woman in her 60s living in Meilan Village, Kaohsiung County, complained about the situation to free clinic doctors. She continued: "The medicine from the public health clinic is not always effective, and it is very hard for us to go down the mountain to see a doctor." The inconvenience of transportation and the inadequacy of medical resources prevent her from receiving the full benefits of the national health plan.

A 65-year-old aboriginal man had a car accident three years ago, and now he has developed high blood pressure. He shook his head and sighed that he had to toil back and forth up and down the mountain between his home and the hospital for rehabilitation therapy. He finally gave up and stopped going to the hospital. "I would go if there were free medical service [on the mountain]," he said, "but since there isn't, I just stay home."

In many mountain areas, there are public health departments staffed with doctors, but in more remote areas, there are only public health nurses in small clinics. Sometimes there is not even a clinic, so people with serious illnesses have to travel for hours down the mountain. We often hear of people dying before reaching the doctors.

Local residents must simply endure minor illnesses . Sometimes, the local nurse writes down the symptoms on a piece of paper and faxes it to the health department. A doctor there faxes back the prescription, and the nurse prepares the medicine for the patient. Mistakes do happen, but this is the only way that some residents can get any treatment at all.

"Some people told me that if they wanted to see a dentist, they had to walk for more than 100 kilometers [62 miles]," said one doctor. "These people pay the same premiums, so there shouldn't be such a big difference in services."

No Doctor, No Service

Dr. Chen Shen-fa, specialist in Chinese traditional medicine and also a Tzu Chi commissioner, goes to aboriginal tribes in the mountains and on offshore islands to provide free clinics. He observed that there was only one public health clinic and one military clinic on Lutao, a small island off the southeast coast of Taiwan. He said that if any patient was seriously ill, he would have to make a rather dangerous boat trip to Taitung for treatment.

One time, Dr. Chen had just finished a free clinic in Liehyu Village on an islet near Kinmen Island, to the northwest of Taiwan. Just as he was about to get some rest, a man rushed in, carrying his sick child in his arms. The child had spasms and a fever of nearly 40 degrees Celsius [104 F]. Due to the limited amount of Chinese herbs in the shops on the island, Dr. Chen used some substitutes. The fever was gone the next day, but there was no doctor at the only health clinic on the island. According to local residents, the doctor, who lived on the main island of Kinmen, had already gone home that evening. Frequently, if the seas were too rough, the doctor could not come at all.

In order to encourage physicians to work in remote areas, the National Health Bureau has increased the pay for doctors in those areas. Nevertheless, many doctors are still reluctant to go.

Most doctors feel that their families are the major factor. They have to consider their careers and their children's education. Besides, medical equipment is rather inadequate in these remote places, and there are not many scholarly medical seminars. Doctors worry that they cannot improve their skills in the long run. These are the major reasons why doctors do not want to be stationed here.

According to Dr. Chen, doctors who serve in a hospital for a long time become famous. Many of them want to open their own clinics, and this is a major problem for understaffed hospitals in remote areas.

Hospitals in these places are usually underequipped as well, so patients with serious illnesses must be transferred to larger hospitals. However, hospitals can't go on without doctors. In Penghu, a group of islands to the west of Taiwan, Makung Chinese Medicine Hospital is closed because not one doctor can be found. A Catholic hospital on the same island is also facing the same problem.

HOME CARE
Extending Medical Service Beyond the Hospital

By Yeh Wen-yin
Translated by Lin Sen-shou

The Tzu Chi Foundation opened a free clinic in Hualien 24 years ago, calling on all local doctors, nurses and Tzu Chi volunteers to help with the foundation's first free medical service.

Tzu Chi Hospital was opened 14 years later to continue serving the people in Eastern Taiwan and its remote mountain areas. The hospital's free clinics and health patrols have never stopped. The hospital acts with the heart of a local resident to serve the local residents.

Dr. Tseng Wen-pin, director of Tzu Chi Hospital, feels that if free clinics cannot be held at the same time and place every year, their effectiveness will be greatly reduced. He remarks that short-term, irregular clinical service cannot meet the needs of local health care. It can only treat colds and stomachaches. Complete health care still requires constant, regular medical service and health guidance.

For ten years, Tzu Chi Hospital has sent out medical personnel and volunteers to serve families that have been receiving Tzu Chi's assistance. In July 1994, it also established a Chinese medicine free clinic for remote villages to fully realize the importance of medical care outside the hospital.

Amiable Relationship

"Although the national health insurance plan reduces medical expenses for the general public, complete medical care must still include prevention of illness," says Wang Li-jen, senior specialist of the Tzu Chi Foundation Medical Development Committee. "When a person is ill, we have to look for the cause or causes from biological, psychological, educational, social, genetic, economic, and even cultural perspectives. In this way, both the body and the mind can be healthy. From this we know that maintaining one's health is not only the responsibility of the doctors."

For example, free clinics in the mountains are a medical model that combines doctors, public health nurses, rehabilitation specialists, social workers and local specialists to bring medical care close to the residents. Through medical intervention, aboriginal communities become aware that living habits and cultural differences generate very serious health problems. Hospital staff members try to find a way to improve the situation to make the communities healthier.

Dr. Tseng Kuo-lieh of the Tzu Chi Hospital Chinese medicine department is constantly involved with free clinics in mountain villages. He commented that doctors in hospitals can only make prescriptions or provide suggestions based on patients' descriptions of their symptoms and their environment. Once they come in contact with patients in their communities, they can discover the factors that affect the patients' health. In addition, providing free clinics is a very amiable experience for doctors and patients. When patients see physicians treating them in their own houses, they usually feel grateful and respect them even more.

Expanding Medical Service

Dr. Wang Yin-wei, director of the Tzu Chi Hospital pediatric department, also emphasized the three factors of timing, location and personnel to continue the free clinics. He felt that people are separated by location, race, religion, culture, and customs, but medical care is the best way to enter local communities and to bridge the gaps.

The medical care provided by the hospital to the communities in the mountains is offered through doctors' prescriptions and treatments, disease prevention, health guidance, evaluation of the community educational environment, and transfers of patients to other hospitals. Medical care also includes lectures on health in the communities and at schools to raise local residents' awareness in maintaining their own health.

In order to improve the health of residents in remote areas and to greatly increase the prevention of illness, the Tzu Chi Hospital management board is proposing to the Health Insurance Bureau that medical services such as oral hygiene and the prevention of tuberculosis and cervical cancer be provided in these remote places. The hospital also plans to purchase vehicles equipped with X-ray machines and other equipment, so that it can bring the good will of the hospital to remote areas and extend the spirit of the free clinics.

FEELING THEIR PULSE

By Chen Chiu-shan
Translated by Norman Yuan

For the past five years, weather permitting, Dr . Chen Shen-fa has flown to Penghu every month to provide free care to families under Tzu Chi's long term care program. He has also visited aboriginal villages on Kinmen, Green Island, Little Riukiu, Sanming County and Taoyuan County.

Perhaps many people have the same problem * they want to serve society, but they don't know how and where to start.

In 1992, traditional Chinese medical doctor Chen Shen-fa told Master Cheng Yen of his wish to serve people. The Master encouraged him to do what he could with his special knowledge. Chang Kuei-sang, a Tzu Chi commissioner from Penghu, happened to overhear what he said. Worried about the inadequacy of medical care on that off-shore island, she took the opportunity to invite him to give a free clinic there.

For five years, weather permitting, he has flown to Penghu every month to provide free care to families under Tzu Chi's long term care program. He has also visited aboriginal villages on Kinmen, Green Island, Little Riukiu, Sanming County and Taoyuan County.

Uncompromising Quality

Dr. Chen, chairman of the Traditional Chinese Medicine Association, always notifies local health offices in writing before he starts each trip. Seven days before the trip, he prepares the medicine. To meet Master Cheng Yen's high standards, he always selects the best quality herbal medicines.

Most patients he serves have chronic diseases such as diabetes, high blood pressure, etc. He keeps complete records so as to check on their progress and to adjust his prescriptions accordingly.

Most residents have very low incomes. Once the medicine is used up, they can't afford to buy any more. Dr. Chen always gives each patient enough medicine for one month so that their supply can last until he visits them again the following month. This way their treatment will not be interrupted.

He has visited other small islets around Penghu, such as Wangan, Chimei, Chipei, etc. From May to August each year, when the sea is calm, he goes to those islets by speedboat. At other times, he phones his patients and mails the medicine to them.

Because of the free treatment and free medicine, Dr. Chen has developed a special relationship with his patients. They trust him. They tell him everything, including their personal problems and family gossip. Dr. Chen, who used to wait for patients in his air-conditioned office, has special feelings towards patients on those islands.

In the Tzu Chi Foundation anthem, there is a verse: "Have pity on the poor and sick, walk on long streets and narrow lanes to visit them; have pity on the poor and sick, give them medicine, food and money." This verse, which frequently comes to Dr. Chen's mind after a free clinic, describes the kindness and compassion of Buddha. Dr. Chen is always amicable toward his patients, and he gives them confidence for recovery. He cures not only their diseases, but also their hearts.

Chatting About Family Affairs

During a free clinic, in addition to the doctor, we need people to register patients, measure their blood pressure and distribute medicine. All these people are Tzu Chi volunteers who have been specially trained. Their amiability impresses the patients very much.

Most volunteers are housewives or employees of private companies. If the free clinic does not fall on holidays, they have to ask for leave from their organizations or make special arrangements at home. Tzu Chi members in Kaohsiung said, "Asking for leave certainly causes inconvenience, but as long as our work is not affected, we will do it." They want to grasp every opportunity to serve people.

"My son is in grade school," said Sister Wen Yu-hsiang. "Sometimes he grumbles. I have to soothe him with patience." She was anxious to do volunteer work. On the other hand, she cared about the feelings of her family. Sister Chiang Kuei-mei, whose husband is always with her in her volunteer work, said, "When I was young, I also received material aid from the United States. Now I have the ability to help others. I ought to come out to serve my own compatriots."

Future Prospects

"In order to make the free clinic more effective, we need systematic planning and consolidation." Dr. Chen expects that this can be done by combining traditional Chinese medicine and Western medicine, doing minor operations, pulling teeth and taking X-rays.

Dr. Chen hopes that the free clinic experience can reflect the uneven distribution of medical resources. He also hopes that people living in areas with rich medical resources will not abuse them, but will do something to help those who live in places where medical resources are insufficient.

Bringing Health to the Mountains

By Ho Cheng-ching
Translated by Norman Yuan

"Actually, national health insurance is a kind of free clinic. Theoretically, we don't need any more free clinics, but we still continue to provide such service. On the one hand, we want to give actual help to people in need. On the other, after we understand the situations in different places, we can render information to our government for reference, hoping that one day no more free clinics will be needed in Taiwan." * Dr. Liu Chi-chun, director of the Taipei County branch of the Taiwan Medical As.

Founded in March 1995, the Taipei County branch of the Taiwan Medical Association consists of more than 100 doctors and nurses, all with special licenses. "Bring health to the mountains" is a series of free clinics that they have carried on each month since December 1995.

In the beginning, the free clinic team considered giving periodic services at fixed locations. However, after their first try, they found that too many places needed their ser-vices, and that one free clinic a month was far from adequate. In the long run, the work needed to be done by the government. Therefore, the team changed to a patrolling clinic style by which they could travel everywhere on the island to find out the actual situation in each area. They could then make proper suggestions to the different authorities concerned.

Emphasis on Efficiency

To avoid duplication and waste of medical resources, the free clinic team only visits remote places inhabited by aboriginal tribes, where there is only one small nurse's office or none at all * in other words, places where there are no medical resources. Transportation is another consideration. If transportation is convenient, inhabitants can easily come out for treatments. To a free clinic team whose time and money are both limited, efficiency is of the utmost importance. Before each trip, they have to make sufficient preparations. Dr. Liu contacts such organizations as World Prospect to find out which place need their services the most. Then he himself travels to each area to assess the situation, th notify the villatge leader, churches and schools and to arrange lodging and meals for his team members.

Based on the assessment , traditional Chinese medicine doctors, Western medicine doctors, dentists, pharmacists, physical therapists, technicians, and nurses are organized. Along with all their necessary equipment and supplies, it is like a travelling general hospital. After each clinic, they leave treatment records and test reports at the local health office and with individual patients for follow-up treatment.

"It is better to teach people how to fish than to give them fish." Everywhere they go, team members give seminars to teach local inhabitants how to protect their own health and prevent disease. In those places where they can't visit very often, such education is essential. They also help academic institutions and scholars make health studies by distributing questionnaires so that the answers can be used in related studies.

Cooperation With Other Organizations

Although most members of the free clinic team are from the Taipei County branch of the Taiwan Medical Association, the patrol model attracts doctors and volunteers from other places. Dr. Liu says that as long as they can do their jobs well, the patrol team does not impose any restrictions on their participation. There is no discrimination of religion or political background. Some doctors are Tzu Chi members, such as Dr. Lien Su-chuan from Tainan.

The free clinic team often cooperates with other social organizations that are familiar with local situations. This way, they can get more information and take better care of the inhabitants. In Nantou County, for example, there are several families in the Tzu Chi long-term care program. Tzu Chi people know that area very well, so Dr. Liu contacted them and personally went to inspect the area and confirm the need for the team's services. Since then, three free clinics have been held there, for which Tzu Chi has arranged lodging, food and transportation.

The free clinic team worked together with World Prospect and Tzu Chi members in Nantou to save one young man's life. In October 1996, some villagers asked them to see a young alcoholic who always had wine instead of rice for his meals. As a result, he suffered from malnutrition and he was nothing but skin and bones. His younger brother and sister had already passed away because of the same problem.

The doctors predicted that if he were not hospitalized right away, his life would be in danger. They asked the social workers to convince him to leave the mountain and go to the hospital. However, he had no money to pay all the expenses. Tzu Chi people subsidized him and gave him care afterwards. His life was saved with the cooperation of all three sides.

Working for Improvement

Most people have the impression that doctors are people who enjoy high status and high income and who live in ease and comfort. But we don't see any arrogance in the doctors of the Taipei County free clinic team. "Their respect for their profession, and their patience and amiability toward their patients are really admirable," say Tzu Chi members who have worked together with them. "They really do a good job. They sacrifice their free time and go far into the mountains. It is really a great burden for them both spiritually and physically, but they keep on going. It is not very easy for them."

The result of their hard work will be presented after they have completed their tour round Taiwan. Then they will make suggestions to the appropriate government health offices for their reference. They hope that in this way, improvements can be made in the uneven distribution of medical resources between cities and rural areas.

What if there is no response from the government?