In mid-summer of this year, a number of health food customers started realizing that the source of their headaches, dizziness, and severely upset stomachs was a product labelled “Promise You Strength and Power/S-Enzyme.” After complaints started pouring in to the Fair Trade Commission and the Investigation Bureau, Ministry of Justice, health officials were urged to check the product. Instead of building one's “vital energy” and assisting the cure of everything from athlete's foot to mental disorders, the product turned out to be better for boosting the growth of chickens and pigs. In August, a local fodder producer was prosecuted for selling this animal feed additive as a health food for humans through an ambitious pyramid sales scheme. The company's network of fifteen thousand salespeople, who relied on personal eloquence rather than advertising on the product's label, had achieved sales of US$23 million since January. The case has helped focus attention on public health issues.
Health official Lai Mei-shu---”Our citizens care about their health, but they are ill-informed and are easily attracted by shortcuts to better health.”
At the heart of public health is public knowledge---of everything from personal hygiene, diet, and food sanitation to basic understanding of physiology and the causes of disease. Ideally, such education begins early, with instruction at home and at school, and lasts a lifetime. But health professionals and educators are concerned that public health standards in Taiwan are far too low. “Our citizens care about their health, but they are ill-informed and are easily attracted by shortcuts to better health,” says Lai Mei-shu (賴美淑), director of the Bureau of Health Promotion and Protection, Department of Health (DOH).
To find out why, look first at health education in the schools. Students from the fourth to sixth grade, for example, receive only one hour of personal hygiene and health education per week. From kindergarten to third grade, no classes are required, although many teachers occasionally provide personal hygiene instruction. In the first-year of junior high, the requirement is just two hours per week; there are no health classes in the second and third year. Moreover, a large proportion of those teaching these classes have had no formal training in health education.
The tooth fairy wants to keep this one! Kindergarten students line up for an annual checkup, including oral hygiene, conducted by a community health station.
In Taiwan's senior high schools, access to health education varies. Females are required to take a one-hour class each week on nursing and health care (and if they go on to college, two hours per week for two semesters). But at both high school and college, males take military training courses instead. “Consequently, females generally have a better understanding of health and hygiene than males,” says U.S.-educated Laura Pan Lu (呂槃), a retired health official and professor who taught for nearly two decades in the Department of Public Health at National Taiwan Normal University.
Many educators agree that it's time for change. “The stereotyped role distribution between the genders shows that our present educational system has not been liberated from the martial law ideology which holds that men should go to war and women should become nurses,” says Wu Shwu-jen (吳淑真), a lecturer in health education at Van Nung Institute of Technology.
But Han Chi-sui (韓繼綏), deputy-director of the Student Military Training Department, Ministry of Education, points out that the military training courses incorporate some health education into their syllabi. For example, senior high students learn first aid and treatment of injuries, while college men receive instruction in hygiene as part of their training. “The health education for males certainly differs from that for females in quantity and depth,” Han says. “But the syllabus is based on the inherent physical differences between men and women, as well as their differing social responsibilities.”
Other complaints focus on the standardized textbooks. The two-volume textbook used in junior high school, for instance, contains sections on physical and psychological health, nutrition, safety and first aid, disease prevention, and family and community health. The problem in this case is selectivity. “Many teachers feel that there is insufficient time to cover all the material, so they often ask that course content be cut back,” Laura Lu says. “As a result, some practical exercises, such as teaching people how to take their own temperature, have been eliminated. So now many people go to the hospital just to have it done for them. This is one example of why many people's self-care capabilities are weak.”
Health station director Lee Meng---”A shortage of staff is the main factor affecting the efficiency of our work.”
Wu Shwu-jen complains that the textbooks are not tailored for their readership. Too often, she says, they incorporate theories that are important for health care professionals but omit subjects that have direct bearing on students. Sex education, for example, is dealt with in a cursory manner. Many basic statistics are also outdated. One of the most obvious is the scale of norms for height and weight for each age group. In recent years, students have generally become much taller and heavier, the product of a higher caloric intake and a diet increasingly rich in meat and milk products. The texts reflect neither the major changes in eating habits and physiological structure nor people's concern about them.
Laura Lu says some efforts are being made to recast the form and content of these books, most of which were written by professors of medicine. “New texts---slated for release in a couple of years---are now being written by people with pedagogical experience,” she says. Meanwhile, teachers themselves have to compensate for the inadequate teaching materials.
Wu Shwu-jen, for example, gives lectures for the first three weeks of class, then turns to group discussions in order to determine topics for future meetings. In some sessions, students give oral presentations or short plays on health-related topics. Recent examples have included sports injuries and slide presentations on public health hazards, such as uncollected waste. Some teachers now supplement texts with video-tapes on subjects such as nutrition, industrial hazards, and environmental protection.
But many educators believe that the real crisis threatening health education is indifference on the part of school administrators and students themselves. “One former student of mine, who is a qualified health care teacher, came to see me and complained that she was forced to teach five subjects, including geography, physical education, and music, for two hours each per week, instead of her health classes,” Laura Lu says. “Some principals just don't respect our professional training. They are ignorant of the importance of health education.” Wu Shwu-jen has similar worries about her students' attitudes. “Most of my students just don't care what they can learn from this course.” she says. “They think it's irrelevant to their future careers.”
Student Tzeng Yuh-shan (曾鈺珊), a junior in the Department of Chemical Engineering at National Taiwan University, not only confirms Wu's concerns, she indirectly puts the blame on the system. “Like me, most of the students don't pay much attention to the [nursing and health] courses,” she says. “We attend the classes because we have to. We don't think the material is impractical or irrelevant, but we're not graded in this class, so it has no bearing on our grade point averages. Why pay attention?” In short, grades count most, and that's where students will put their energy.
A stock of wisdom or misinformation? Bookstore owners recognize that health-related publications have become sure-fire sellers, but readers need to scan them with critical eyes.
Department of Health officials have recognized that public health education in the schools isn't effective enough and have stepped in to help. Six years ago, for example, the DOH asked dentists in private and public practice to work with principals and teachers on an oral hygiene pilot program in elementary schools. The dentists gave lectures and distributed free toothbrushes, and the teachers regularly tested the effectiveness of their students' after-lunch brushing, awarding prizes for the cleanest teeth. In 1993, the program was expanded and the Ministry of Education took over responsibility for implementing it. Currently, more than six hundred of Taiwan's twenty-five hundred primary schools are using this program to promote oral hygiene among their students. By the end of 1995, the number is expected to reach nine hundred.
As children get older, public health education becomes even more complex. “In promoting public health to adolescents, it's no use preaching about what is good or bad, because they are in the midst of their rebellious phase,” says Lai Mei-shu of the DOH. “We have to try more sophisticated tactics to move them.” One has been to turn to the private sector for help. This has proved effective in teaching Taiwan's youth about the dangers of alcohol, tobacco, and other drugs.
Please take one---The increasing number of pamphlets distributed by the Department of Health through schools, health stations, clinics, and hospitals are helping build much needed public health awareness.
For example, the DOH retained the John Tung Foundation (an organization set up in 1984 by Hong Kong entrepreneur John Tung to fight smoking and promote nutrition, health, and children's education) to produce an anti-smoking campaign. It has turned out to be successful in attracting widespread attention. The campaign materials, including video-tapes, stickers, pamphlets, and placards, are highlighted by “Hsu Tze-lin,” the creation of popular cartoonist Chu Te-yung (朱德庸). Hsu is a hip, street-wise kid who wears an earring, sunglasses, and baggy pants held up with suspenders. His name is the reverse of Lin Tze-hsu, a famous Ching dynasty official who was a devoted anti-opium crusader. As the campaign's spokesman, Hsu holds a no-smoking sign and promotes ideas such as, “First-rate citizens refuse second-hand smoke.”
The DOH has also urged pop singers and other teen idols to do promotional spots on television and at various youth events. “Via the pop singers, we send the message that refusing to smoke or take drugs is 'cool,''' Lai says. “We hope that young people can accept the idea.”
Adolescents with insufficient health education eventually become inadequately informed adults, which aggravates community health problems such as poor public sanitation and infectious disease. Many adults are therefore easily deceived by the claims made for health products and patent medicines advertised in the mass media. And judging accuracy has become increasingly difficult as the number of health food products on the market has increased---some genuine, others bogus or questionable at best, including shark oil, curative herbal teas, and at least one “health” coffee. DOH statistics indicate there are more than seventy producers of health aid products in Taiwan, and fifteen hundred health foods are being legally imported, but many others---especially from Mainland China---are brought in illegally. Annual sales of health foods are estimated to exceed US$1 billion, and health professionals regularly complain that the manufacturers of these products make wildly misleading claims about their qualities.
As people become hungrier for accurate information about becoming and staying healthy, the media have started to carry a wide range of health care reports. Numerous television programs feature discussions and interviews about self-care and nutrition, and many are punctuated with commercials for health foods claiming to cure migraine headaches, arthritis, and other aches and pains. Bookstores, recognizing that anything on health and medicine is a sure-fire seller, reserve special sections for such publications.
“The media are one of the main conduits through which people learn about personal health care, but they don't always exercise good judgment in differentiating between valid reports and dubious sales pitches,” says Laura Lu. “In many cases, experts offer conflicting views that further confuse the public. I am particularly worried about the revival of traditional Chinese folk treatments of questionable effectiveness, such as cupping and Chinese herbal medicines, which are increasing as the contacts between Taiwan and the mainland become more frequent.” Lu worries that public health awareness may in fact be declining rather than improving.
To provide better guidance on health care issues, the DOH has sponsored numerous public awareness campaigns in cooperation with educational institutions, the health care industry, and the mass media. These have focused, for example, on personal hygiene, anti-smoking, AIDS awareness, and communicable disease prevention. But the promotion of health education among adults has proven to be particularly difficult. Old habits are not easily changed. While adults, especially those who have reached middle age, are more motivated than adolescents to learn about health care issues affecting their age group, it is difficult to disseminate promotional and educational materials to them. “We have difficulty in hitting our target,” says Lai, pointing out that adults cannot be reached as easily as infants, who are regularly taken to hospitals by their mothers, or as those still in school.
Don't turn your back on sanitation---Health station staffs have many duties. One is to promote higher standards of food preparation and service.
As a result, many campaigns focus on subcategories of adults, such as those suffering from hypertension, diabetes, or other chronic diseases. These are carried out with the assistance of various national health organizations, including those focusing on family medicine, diabetes, and internal medicine. Diabetics, for example, are given reliable access to blood pressure and blood sugar tests from community health stations, and hospitals are encouraged to establish centers for distributing educational materials to diabetics and their families.
One important source of public health information and education is the network of 350 government health stations located in cities and towns throughout the island. These provide community medical care in out-patient clinics and offer services in such areas as maternal and child health, family planning, school health programs, laboratory tests, immunization, and the prevention and control of acute and chronic diseases. They are also on the front lines of public health awareness campaigns.
Student nurses in Taipei take a break from classes. Those who eventually work in health stations may find their days enlivened by the friendships they form with patients during house visits.
Nurses at health stations, using records provided by public hospitals and clinics, are responsible for identifying and visiting chronic patients at home to observe their condition and to answer any questions about health and medication. The frequency of visits depends on the nature of a patient's affliction. For example, TB patients get weekly visits, while hypertension patients get monthly visits. As a result, patients build close friendships with their nurses and have confidence in the advice and information they provide. “The relationship between me and my patients is so intimate that many of them reveal things to me that they wouldn't tell their families, and this helps my work a lot,” says Lu Shu-chuan (呂淑娟), head nurse at the Tamsui health station in Taipei county. “Most patients, even those who tend to rely on untested alternative medicines, eventually agree to abandon them and to take the medicine we provide.”
The house call system helps patients and their families acquire essential information about medical and self-care treatments. But health station nurses are allowed only a half-day for such calls. The rest of the day they do jobs such as providing vaccinations at nurseries and primary schools and conducting health promotion programs on nutrition, household hygiene, mental health, and communicable disease prevention. In Taipei county townships, the average health station has twelve nurses and one doctor, which guarantees heavy workloads. “A shortage of staff is the main factor affecting the efficiency of our work,” says Lee Meng (李孟), director of Tamsui health station.
Health station director Liang Chung-tao---”We should start placing greater emphasis on health education and promoting disease prevention.”
Many health care professionals recommend that health stations solve their overwork problem by cutting back on services that are now more widely available elsewhere in clinics and hospitals. “We should start placing greater emphasis on health education and promoting disease prevention, rather than the diagnosis and control of communicable diseases,” says Liang Chung-tao (梁忠道), director of the Tucheng health station in Taipei county. Pien Ming-yu (卞明玉), a public health nurse at the station, voices a similar sentiment. “Before, if asked what the main function of a health station was, people might have answered that it was to provide vaccinations,” she says. “Now, when a new pharmaceutical product or medical treatment is announced, the next day we'll get about seventy phone calls asking for information.”
Lai Mei-shu of the DOH considers public health education to be more important than ever because people are changing their ideas about health. In the past, she says, people attributed the causes of illness to noxious substances in the external environment. “Originally, we protected people from communicable diseases by giving them antibiotics or improving environmental hygiene, but now we're primarily dealing with personal behavior,” she says. “It's harder, because it involves changing personal motivation and building the will to do what needs to be done.” The overall message, however, is simple: “An ounce of prevention is worth a pound of cure.”