The British author, Eve Garnett (1900-1991) was born in Worcestershire, England, and had a comfortable, middle-class upbringing. She became inspired to write children’s literature after moving to London in the 1920s for art school and witnessing the stark social division and living conditions of London’s poor.[1] These experiences fueled a lifelong mission to bring attention to poverty and to give children from urban, working-class backgrounds stories that reflected their own lives. Her first book, The Family from One End Street, was published in 1937. It is the first of three books about the Ruggles family, consisting of Mr. Ruggles, a town dustman¹, Mrs. Ruggles, a washerwoman, and their seven children, from teenage Lily Rose to infant William. The subsequent books, Further Adventures of the Family from One End Street (1956) and Holiday at the Dew Drop Inn (1962), take place immediately after the first. Set in the fictional English town of Otwell between WWI and WWII, the series describes the adventures and hardships of the Ruggles family with humor and poignancy. 

In the second book, Further Adventures of the Family from One End Street, a measles outbreak is the inciting event that sets the plot into motion. The eldest, Lily Rose, is the first to be stricken as “her head ached, she felt hot and cold by turns” and then she looks in the mirror to find her face is “bright pink, and covered all over with small red spots!” The doctor is called to their small and crowded home, and he advises Mrs. Ruggles, “You can’t keep her here, you know – nowhere to isolate her and no time to look after her if you had; it’s the isolation hospital for measles these days. I’ll have the ambulance round in half an hour and someone to disinfect that room for you. ‘The others?’ no, they certainly can’t go to school, but don’t you worry, they’ll probably all have it in a few days and be off your hands in the hospital too!” 

Management of measles and other infectious diseases was particularly challenging among the urban poor, who lived in crowded conditions. Because the nine Ruggles live in tight quarters in a “very old and very small” house, the remaining six Ruggles children are at risk for catching measles from Lily Rose.² Infection can also easily spread beyond the Ruggles household to the rest of the neighborhood. To help contain the infection, patients were sent to isolation hospitals, which were standalone institutions dedicated to treating infectious diseases in the pre-antibiotic and pre-vaccine era.  

The evolution of isolation hospitals was shaped by public health efforts throughout the 1800s and the medical acceptance of germ theory by the 1880s. The first fever hospital in England opened in 1801.[2] Early fever hospitals were run as private charities for the poor and featured open-planned rooms where patients suffering from different infections were packed side-by-side. These places were mocked as houses of death because someone admitted with a mild case of one fever could catch an entirely different, fatal infection from the patient in the next bed. Over time, laws established public health funding and regulation for isolation hospitals. The Sanitary Act of 1866 gave local authorities explicit power to provide hospital accommodation for infectious disease, a power consolidated by the Public Health Act of 1875.[3-5] Later, the Isolation Hospitals Act of 1893 empowered county councils to build new isolation hospitals where needed, leading to a national network of specialized isolation hospitals designed in accordance with modern germ theory.[3,6] By WWI, there were more than 750 isolation hospitals in England and Wales.[7] These new isolation hospitals emphasized cleanliness and good ventilation, and featured separate wards for different infections.[7] Thus, when Lily Rose develops measles in the 1930s, the doctor recommends she be admitted to a dedicated measles ward of a modern isolation hospital for quarantine and care.³ 

Hypothetically, if Mrs. Ruggles objected to Lily Rose’s hospital stay, the doctor may not have had a pathway to mandate her admission in the 1930s. The Public Health Act of 1936 gave local health authorities a legal mechanism to apply to a justice of peace, who could then mandate the admission of a patient to an isolation hospital if they had a notifiable disease, home isolation was not possible, and they posed a serious risk of infection to other persons.[8] However, measles did not become a nationally notifiable disease in England and Wales until 1940.[9] Before 1940, it was up to individual towns to make measles notifiable and enforce isolation, and Eve Garnett does not specify if such laws existed in Otwell. 

Despite Lily Rose’s prompt quarantine, her younger siblings Jo and Peg also develop measles and are sent to the isolation hospital. Mrs. Ruggles may have been particularly grateful for the supportive care of isolation hospitals in Jo’s case as “the doctor said Jo was a very sick boy, and told Mrs. Ruggles downstairs it was always worse if the spots stayed in, and the sooner Jo was in the hospital the better!” What the doctor is referring to is that the measles rash typically appears 3-5 days after the first symptoms of fever, cough, coryza⁴, and conjunctivitis; if the rash onset is delayed or “the spots stayed in”, it is a signal that the body is struggling to fight the virus. A late, absent, or weak rash is common in immunocompromised, malnourished, and very young children whose immune systems are not fully developed; these patients are at increased risk for severe systemic complications.[10, 11] While Lily Rose is described as a robust 13-year-old girl who only has a “mild attack”, 7-year-old Jo and 5-year-old Peg suffer more serious attacks and have a longer road to recovery. This is especially true as measles is now known to cause immune amnesia, a condition where the virus depletes patients’ pre-existing antibody repertoire, leaving them vulnerable to other infections for two to three years afterward.[12]  

Upon discharge from the hospital, Peg and Jo have clearly lost weight, are still quite weak, and need further treatment. After a conversation with the doctor, worried Mrs. Ruggles updates her husband, “Peg and Jo’s got to be fed up with malt-and-oil when they comes out, and Jo’s that pulled down, the doctor says as six weeks in the country’ll barely set him up”. The oil the doctor recommends to Mrs. Ruggles is cod liver oil, which transitioned from a folk remedy to a mainstream, multi-purpose medical treatment in the 1800s. However, doctors did not know why some patients benefited from cod liver oil until medical research in the early 1900s discovered vitamins and diseases of vitamin deficiency. Cod liver oil was discovered to contain vitamin A in 1913 and vitamin D in 1922.[13,14] And, as discussed in the first part of this MedHum series, the therapeutic value of treating measles patients with vitamin A was demonstrated in 1932.[15] The high caloric content of cod liver oil also helped with malnourishment. Unsurprisingly, children hated the taste of cod liver oil, so malt-and-oil was developed as a commercial pharmaceutical product in the late 1800s, whereby the fishy oil was mixed with thick, sweet malt extract to make it more palatable. Mrs. Ruggles, who has not tasted the malt-and-oil, puts this mixture to the test when she “hold[s] a spoonful out to” suspicious Jo and coaxes him with hopeful reassurances, “It’s not medicine, nor yet oily – more like soft toffee”. She heaves a sigh a relief when he swallows it without resistance, “Thank Heaven he liked it!” 

By sacrificing their meager savings, Mr. and Mrs. Ruggles are able to follow the doctor’s other recommendation to send Jo and Peg (along with their 12-year-old sister Kate) to stay with Mrs. Wildgoose in countryside for recovery. Throughout the 19^th and early 20^th centuries, sending urban children to the countryside to recover from illness was standard practice; the rationale was plausible in cities plagued by industrial smog, poor sanitation, and overcrowding. When Mrs. Wildgoose meets the children, she says “she could see from the look of Peg and Jo how important [malt-and-oil] was, but mark her words, before the three children had been a week at the Dew Drop Inn, eating the eggs from her ducks and hens, good farm butter, and drinking milk from Mr. Digweed’s cows, they wouldn’t know themselves!” It may be universally agreed upon that eggs and dairy are a more palatable way to consume calories and fat-soluble vitamins than cod liver oil. The children do indeed have a marvelous time at the Dew Drop Inn – their countryside explorations and misadventures make up the core of the book – and they make a full recovery attributed to fresh air, sunshine, exercise, and good food. And when they return home, “How [Mrs. Ruggles] hugged and kissed them all, exclaiming again and again at Peg and Jo’s bright eyes and round, fat, sunburnt faces – so different from the pale, skinny little creatures she had seen off six long weeks ago!” 

Although the book focuses on the children’s perspectives, Mrs. Ruggles’ measles experience is worth acknowledging. She is separated from her children for two stressful months because of measles. She is not allowed to visit them during their weeks in the hospital, as isolation hospitals of the time followed strict quarantine protocols. In fact, the doctor warns Mrs. Ruggles when Lily Rose is first diagnosed, “go down to the hospital this evening if you like but they won’t let you see her.” After Peg and Jo are discharged from the hospital, she sends them to recuperate with Mrs. Wildgoose for six weeks because she cannot afford to take time off of work and she needs to tend to her other four children. No wonder those six weeks felt long, and no wonder she is relieved and overjoyed to see her children healthy again when they return from Dew Drop Inn.  

While the isolation hospital and measles recuperation experience would have been familiar to contemporary readers, it likely feels foreign to readers today. The development of a measles vaccine in 1963 and its implementation in Britain in 1968 – about thirty years after this book is set – dramatically reduced the incidence of measles and contributed to the obsolescence of isolation hospitals.[16] Following the development of highly effective vaccines and antibiotics in the mid-1900s, isolation hospitals were systemically closed or repurposed. Measles was declared eliminated by the World Health Organization in the US in 2000 and in the UK in 2017.[17,18] For a period of time, measles was relegated to a bygone era, just like doctors’ prescriptions for malt-and-oil and country air. However, as vaccination coverage has fallen, measles has returned. The UK lost its measles elimination status for a second time on January 26, 2026, and the US is predicted to follow.[18,19] As a result, Further Adventures of the Family from One End Street is somehow pertinent again in its depiction of measles as a contemporary childhood malady.  

¹ Dustman is a traditional British term for garbage collector, which is considered old-fashioned today. 

² This quote is taken from the first book, The Family from One End Street. 

³ The development of isolation hospitals in the US followed a similar timeframe. In the US, the first isolation hospital was opened in Philadelphia in 1801 following a series of yellow fever epidemics. During the late 19th and early 20th centuries, state statutes across the US codified the mandatory construction of municipal isolation hospitals to control epidemics. Because public health powers are granted to states under the U.S. Constitution’s 10th Amendment, individual towns and state boards of health passed the earliest mandatory measles isolation laws in the late 1800s, and measles became a nationally notifiable disease in 1912. 

⁴ Coryza is the medical term for acute inflammation of the mucous membranes inside the nose, commonly known as a runny nose. It is one of the “three C’s of measles”, a traditional medical mnemonic used to teach medical students the standard early clinical presentation of measles – cough, coryza, and conjunctivitis.  

References 

1. Eve Garnett. Penguin Random House. Accessed September 7, 2026. https://www.penguinrandomhouse.com/authors/9731/eve-garnett/ 
2. Currie MR. Fever Hospitals and Fever Nurses: A British Social History of Fever Nursing: A National Service. Routledge; 2005. Accessed September 7, 2026. https://ndl.ethernet.edu.et/bitstream/123456789/9881/1/1072.pdf 
3. Parsons HF. The Hospital Isolation of Infectious Diseases: I. The History of Isolation. Hospital (Lond 1886). 1913;54(1408):357-358. 
4. Great Britain. The Sanitary Act 1866. legislation.gov.uk. Enacted 1866. Accessed September 7, 2026. https://www.legislation.gov.uk/ukpga/Vict/29-30/90/contents/enacted 
5. Great Britain. Public Health Act 1875. legislation.gov.uk. Enacted 1875. Accessed September 7, 2026. https://www.legislation.gov.uk/ukpga/Vict/38-39/55/contents 
6. Great Britain. Isolation Hospitals Act 1893. legislation.gov.uk. Enacted 1893. Accessed September 7, 2026. https://www.legislation.gov.uk/ukpga/Vict/56-57/68/enacted 
7. Currie MR. Fever Hospitals and Fever Nurses: A British Social History of Fever Nursing: A National Service. Routledge; 2005. Accessed September 7, 2026. https://ndl.ethernet.edu.et/bitstream/123456789/9881/1/1072.pdf 
8. Great Britain. Public Health Act 1936, section 169. legislation.gov.uk. Enacted 1936. Accessed September 7, 2026. https://www.legislation.gov.uk/ukpga/Geo5and1Edw8/26/49/section/169/enacted 
9. Public Health Wales. Measles surveillance and epidemiology. Accessed September 7, 2026. https://phw.nhs.wales/reports/measles-surveillance-and-epidemiology/ 
10. Burrell CJ, Howard CR, Murphy FA. Pathogenesis of virus infections. In: Fenner and White’s Medical Virology. 5th ed. Academic Press; 2017:77-104. doi:10.1016/B978-0-12-375156-0.00007-2 
11. Permar SR, Griffin DE, Letvin NL. Immune containment and consequences of measles virus infection in healthy and immunocompromised individuals. Clin Vaccine Immunol. 2006;13(4):437-443. doi:10.1128/CVI.13.4.437-443.2006 
12. Mina MJ, Kula T, Leng Y, et al. Measles virus infection diminishes preexisting antibodies that offer protection from other pathogens. Science. 2019;366(6465):599-606. doi:10.1126/science.aay6450. 
13. McCollum EV, Davis M. Nutrition classics from The Journal of Biological Chemistry 15:167-175, 1913. The necessity of certain lipins in the diet during growth. Nutr Rev. 1973;31(9):280-281. doi:10.1111/j.1753-4887.1973.tb07065.x 
14. McCollum EV, Simmonds N, Becker JE, Shipley PG. Nutrition classics. The Journal of Biological Chemistry 53:293-312, 1922. Studies on experimental rickets. XXI. An experimental demonstration of the existence of a vitamin which promotes calcium deposition. Nutr Rev. 1973;31(5):158-161. doi:10.1111/j.1753-4887.1973.tb05090.x 
15. Ellison JB. Intensive vitamin therapy in measles. Br Med J. 1932;2(3745):708-711. doi:10.1136/bmj.2.3745.708 
16. Sutherland I, Fayers PM. Effect of measles vaccination on incidence of measles in the community. Br Med J. 1971;1(5751):698-702. doi:10.1136/bmj.1.5751.698 
17. Centers for Disease Control and Prevention. History of measles. Updated April 29, 2026. Accessed September 7, 2026. https://www.cdc.gov/measles/about/history.html 
18. Taylor L. UK loses its measles elimination status. BMJ. 2026;392:s172. doi:10.1136/bmj.s172 
19. Bischops AC, Hulland EN, Patzakis M, Majumder MS. Will the USA lose its measles elimination status? Lancet. 2026;407(10540):1679-1681. doi:10.1016/S0140-6736(26)00466-6

Further Adventures of the Family from One End Street 
Eve Garnett 
Puffin Books, 1993. Paperback. 256 pages 
Originally published 1956 

Web image generated by Medhum.org based on the original book cover.

Two hidden stories by two famed authors written decades apart in two countries eventually became widely known. One, Anton Chekhov’s, At the Pharmacy, was translated into English in 1998, about one-hundred years after it was published in Russia. The other, Raymond Chandler’s, It’s Alright–He Only Died, was unearthed from its unpublished state by Strand Magazine in 2018, about sixty years after it was written. Though written in different times, and using different scenarios, both stories warn of the barrier money creates to urgent and necessary health care, and of the corrosion in professionalism it causes in providers. They tell of what was to become a defeating feature of Western health care because of financial incentives, social prejudices, and human folly.

Six Kopecks or Your Life

Peter Constantine reached back from the 1990s into the 1880s to assemble a translated anthology of some Chekhov short stories not available to English-speaking audiences. Among the chosen stories in The Undiscovered Chekhov: Thirty-Eight New Stories, is At the Pharmacy.

The story begins when Egor Alexeyitch Svoykin becomes sick. His physician prescribes medicine that a pharmacy would need to prepare. Svoykin felt some relief being in a large Russian city during the late nineteenth century that would have pharmacies he could count on. This feeling of relief dissipated just after entering the pharmacy and coming before the imperious pharmacist there. 

The pharmacist eventually raises his head from a newspaper, looks at the prescription, shouts instructions to his assistants, and then returns his gaze to the newspaper while at the same time informing Svoykin the prescription will be ready in an hour. Svoykin is the only person waiting at such a late hour as it was, and he was deteriorating.

His mouth was on fire; there was a drawn-out pain in his arms and legs; foggy images tumbled about like clouds and shrouded human figures in his heavy head. He looked as if through a veil at the pharmacist, the shelves of jars, the gas burners, and the cabinets. The monotonous pounding in the marble mortar, and the slow ticking of the clock seemed to him to be coming not from the outside but from inside his head. (p. 129)

When Svoykin reports to the pharmacist that he is becoming feverish and feeling weaker, “the pharmacist “remained stock-still and, leaning his head farther back, kept on reading his newspaper. He didn’t respond to Svoykin with word or movement—it was if he hadn’t heard him.” (p. 130) When Svoykin subsequently approaches the pharmacist pleading with him to hurry the prescription, the pharmacist again brushes him off saying, “It’ll be ready soon enough…excuse me, but there’s no leaning on the counter.” (p. 131)

The next half hour was “unbearable” before the prescription came and then made more so by the dubious rituals the pharmacist performed in adorning the prescription container. The pharmacist charged one ruble and six kopecks, but Svoykin was short the six kopecks. 

Under the circumstances…I would be grateful if you would let me bring you, or maybe send you, the six kopecks tomorrow…

I’m sorry, we don’t accept credit here.

What am I supposed to do?

Go home, get the six kopecks, and then you can have your medicine.

But…I’m having difficulty walking, and I don’t have anyone I can send…

That’s your problem.

pp. 132-133

Svoykin returned home, though with difficulty. The Kopecks were there on the table, but his illness kept him from returning to the pharmacy.

Just Drunk

Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes an unpublished Raymond Chandler short story. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective, Phillip Marlowe. This story, however, written between 1956 and 1958, is about a person brought to a hospital emergency room and denied service for financial and social reasons.

As the story opens, a man who has been hit by a truck is brought into the emergency department at General Hospital. He arrives just before shift change and so the admitting clerk is already annoyed about having to assess him. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. Off the patient goes.   

The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. “It’s all right—he only died.”

Fast Forward

If they could have foreseen the current time when they wrote these stories, 140 years ago for Chekhov and 70 years ago for Chandler, they would have realized that the scenarios they created became commonplace and institutionalized in many ways.

Pharmacists may not go unseen behind a newspaper as Chekhov’s pharmacist did, but they may be buried under insurance company paperwork or piles of prescriptions needing to be filled. And certainly in a few situations, perhaps only independents, do pharmacists have ways to cover costs when patients are short on cash, credit, or insurance coverage. They are very likely to send patients away to get money even when they are very sick.

Hospital personnel do not now actually reach into the pockets of unconscious patients to see if there’s enough cash for admission as Chandler conjures in his story, but he would see them still check for money in the form of insurance cards or proof of sufficient financial means. He would also see that the scenario he described in which patients without money get transferred to county hospitals had progressed to a degree that people are moved around among different health care providers based on health care insurance plan coverage or lack thereof. But the poor treatment of patients in need of emergency care can even occur in the “right” hospitals when they are held for hours to days in hallways or holding wards for beds to become available.

Scenarios such as these can and have been addressed to varying degrees through government welfare programs, regulatory requirements, technology advances, and professional practice standards among other responses. The two stories, though, also expose human folly not so amenable to these actions. What can be done about the pharmacist who won’t put the newspaper down to address the needs of a person seeking help for an acute illness? What can be done about the physician who after a cursory evaluation brushes off an unconscious patient as “just drunk?”

Chandler makes an attempt at addressing the human folly he and Chekhov reveal by describing how it fails humanity on both professional and personal levels, and in shaming the character, who is ostensibly standing in for those behaving as this doctor in the story did.

All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it?  Should it?  

Chekhov and Chandler are perhaps hoping that those in the care of others will exhibit more humane and professional behaviors when they ask themselves many decades later: “Am I a doctor?”“Am I a pharmacist?” “Am I a human being?” Would it make a difference? Should it?

Notes

Title image:
A young girl waiting for a pharmacist to make up a prescription.
Photogravure, 1912, after J. Jendrassik, 1896
Licensed under the Creative Commons Attribution 4.0 International

End image:
Nurse Aide Rocky FordHospital CO
Mennonite Church USA Archives, No restrictions, via Wikimedia Commons

Mrs. Lin is a fifty-five-year-old woman who has lived alone in Canada for many years while her husband lives back in China. Her two sons are both working and out of the house. Last week, she discovered a new breast lump while showering. A few days later, she’s in my clinic to get the lump checked. As her family doctor, I order a mammogram and an ultrasound. When the results of these tests come back a few days later, the report indicates that the findings are suspicious for malignancy and a biopsy is necessary. 

Mrs. Lin returns to the clinic and I relay the information to her. I try not to mention the word “cancer” to her, but it hangs between us, powerful even if it remains unsaid. I urge her not to jump to worst case scenarios, but we both know that one way or the other, this is life altering news. I promise to order a referral to the breast diagnostic clinic at the community hospital nearby and that the breast centre will reach out to her in the next week or two. 

Later in the week, I receive a fax from the breast clinic. They’ve been trying to reach my patient by phone but with no success. Do we have another way of contacting her? 

I instruct my office staff to try to reach the patient. They call repeatedly for a few days. The breast clinic appointment is scuttled but I’m not actually worried. I’ve seen this pattern many times before. I am certain the patient has already flown the coop. 

A few days later, my hunch is proven right. My nurse manages to reach one of Mrs. Lin’s sons. His mother is safely back in China, seeking medical attention there. They’ll call us when she returns sometime next year. 

When my father boarded a plane in Taiwan in 1967 to come to Canada on a one-way ticket for graduate school, my grandmother saw him off at the airport. She gave him $1000 and said, “I’ll see you in about ten years.” 

She wasn’t far off. In fact, he didn’t return to Taiwan until 1974, for his wedding. 

That was what being a Chinese-Canadian immigrant was like back in those days. A journey to the other side of the world was truly a journey into an unknown abyss. Letters marked “airmail” with the blue and red checkered envelope edges took weeks to circumnavigate the globe. If my father wanted to call his parents, he’d reserve the call for special occasions like Chinese New Year because long distance rates were exorbitant. And even then, he’d be careful to limit the call to one minute and fifty seconds because exceeding the two-minute mark meant paying unnecessary fees. 

Immigrating was essentially a one-way trip. Immigrants like my father rarely considered the prospect of flying back home because it was something most of them simply couldn’t afford. There were only two acceptable occasions to fly home: your own wedding or a death in the family. 

The journey for today’s Chinese-Canadian immigrants is different. Not only can they communicate easily with those back home using apps like WhatsApp, WeChat and Line on an hourly basis, but based on my observation of my Chinese Canadian immigrant patients, even those who struggle financially, seem to have a reserve fund that they can dip into and use to return to China on a moment’s notice. Home is never more than a one-day airplane flight away. 

And people fly back for all manner of reasons now: family illnesses, Chinese New Year, summer vacations, and most definitely, for expediting medical investigations. 

The fluidity with which patients move back and forth speaks to a difference in what motivates immigrants to come to Canada. When my parents’ generation left China or Taiwan or Hong Kong, often it was to trade a future bleak of possibilities for a possibly prosperous future. But for many of today’s Chinese immigrants, it’s a trade of one hopeful future, for possibly, a slightly better one, but with the option to go back if this future in the West doesn’t work out. 

Health care has become part of this back-and-forth fluidity. It used to be that the health care trade off would have been clear–Canadian health care was more advanced than that in China in the sixties and seventies. But that’s not entirely true anymore, and today’s immigrants arrive with a great deal more reticence about our health care system. 

Health care always presents unique challenges to an immigrant population. Illnesses imply a degree of immediacy and urgency. They play out on their own timetables – they don’t wait for people to become comfortable with the language or culture of a place before occurring. 

So the new immigrant is forced to face the health challenges of regular life—acute illnesses, chronic diseases, bodily injuries, babies being born, and even the occasional life-threatening-situation without the social support structure that they would have had back home. All this is part of the bargain that the new immigrant strikes with their adopted country. And so they pray that nothing major will befall them, but when something invariably does, what do they do? 

In the previous generations, immigrants here had little recourse but to seek out solutions in the Canadian health care system. Whether their English was up to snuff or not, they were forced to navigate the system here. Many Chinese immigrants like my parents flocked to Chinese-speaking doctors like me in the hope that at least less would be lost in translation if they found a Chinese person holding the stethoscope. 

The modern immigrant though, has the luxury of straddling the line between the Canadian and Chinese health care systems, keeping one foot in China’s health care system and another foot in Canada’s. 

Unhappy with the wait times for elective knee surgery in Ontario? No problem. A doctor in Taiwan or Hong Kong will have you on the table in the OR in a few weeks, not months. 

New discovery of lymphoma? No need to wait for your family doctor to refer you to an oncology clinic and for that clinic to send you for imaging before finally making a decision on treatment—a process that can easily span into months. If you fly back to China, you can walk into a specialty clinic the next day, see a doctor by lunch time and have imaging and an oncology plan done by the end of the week. 

When it comes to China, the western world has a tendency to see things in stark black and white terms: e.g., freedom is good and communism is bad. As a Chinese Canadian physician, I find that this type of thinking carries over to our view of the health care system. Medical students in Canada, are taught that the Canadian health care system is a virtuous, humane social experiment, one of the country’s proudest achievements. It’s drummed into us that it delivers world-class care to the majority of its people. And we’re proud to be trained in it. Sure, it has its problems, but nothing’s perfect. 

There is a hidden side to this curriculum though. If we’re world class here, what about health care systems in other places? What about Africa? What about South America? What about China? 

Perhaps unintentionally, we’re taught to look down on the systems of other countries. We use words like ”developing“ and “evolving” to describe health care systems in these places. But in private, we often shake our heads in exasperation and use far worse language than that. 

These stereotypes were only reinforced when I started practicing medicine about fifteen years ago. The requests of my Chinese patients, often rooted in their own experiences with the health care systems they had left behind, drove me batty on a daily basis. 

I’d try to explain to my patients that, “Yes, that might be the case there. But you don’t really need any of those things.” But it’s hard to convince someone that everything they’ve accepted as truth may not be correct. 

The worse complaint was always about the wait times. This was one that I could not refute. It’s well-known that wait times for medical procedures in Canada are criminally lengthy. But whereas my Canadian patients had nowhere else to go and would just vent to me about the breaking down of our country’s beloved health care system, or try to drive a few hours to Buffalo to get an MRI, my Chinese patients had the luxury of options. They could hop on a plane, land in China or Hong Kong or Taiwan by the end of the week and get whatever they wanted within days, not weeks or months. 

I should point out that the feedback from patients about the Canadian health care system wasn’t always negative when compared to back home. I learned that the fifteen to twenty minutes I allocated to speak to each patient was approximately twelve to eighteen minutes more than they got in the typical Chinese hospital. 

Still, there were many frustrations that I was unprepared for. Patients would return to my clinic armed with reams of paperwork (all in Chinese), documenting checkups and physical exams that they had done overseas: lab tests and CT scans that had no indication for being ordered, medications that they had been prescribed that were not really indicated. 

If modern medicine in the West suffers from an over-reliance on medical imaging and pharmaceuticals at the expense of a more prudent and holistic approach to care, then modern Chinese medicine has become Western medicine’s adopted twin, with all the same problems we have, except with even less sense of restraint and caution. 

Mr. Zhang is a middle aged, Chinese man with diabetes. In China, people routinely retire in their early fifties and one of the perks of retirement is long term health insurance, so even though Mr. Zhang has lived in Canada for almost fifteen years, he still can access Chinese health care whenever he is back home. 

Mr. Zhang isn’t alone in returning home to seek health care. Even those without health insurance often choose to pay out of pocket to access health care in China on a regular basis because the costs aren’t prohibitive 

Because Mr. Zhang travels back and forth between China and Canada on a regular basis (after all winters in Canada are cold), he needs doctors on both sides of the world to help him manage his long-term diabetes. What he’s discovered is that the quality of care in both countries is, for him at least, comparable. The general procedures for diabetes, routine blood testing, and medication adjustments, are similar in both places. But there are some noticeable differences. 

He informs me that in China, the health care system is heavily incentivized by the profit motive. Hospitals make more money if they achieve certain revenue quotas, and this is passed on to the doctors, who in turn pass this mindset down to the patients. 

At the same time, it’s well known to him and all his friends, that in Canada, with a public health care system, cost-cutting is much more of an issue. 

The doctor as gatekeepers of the health care system is sometimes a difficult concept for patients to understand. Doctors in China are not really gatekeepers of the system the way they are in Canada, where doctors spend a great deal of time being instructed on not over-ordering tests. Not all medical investigations are necessary. Extra tests beget extra costs and may engender unnecessary anxiety and have deleterious consequences for the patient-just think about the patient who worries about a lung nodule that will never cause them problems once it’s been spotted on an unnecessary chest X-ray. These are hard lessons that even medical practitioners in the West struggle with at times. For my patients from China, this concept is irrelevant. In a privatized system where patients can pay for what they want, getting an unnecessary MRI is no different than spending money on a fancier car or an extra helping of dessert: nobody really needs it, but if they can afford it, then why not? 

So if I try to explain to my patients why I don’t think they need that MRI they really want, they think I am just trying to save the government of Canada money. If I am really hard-nosed about it, they just might turn around, get on a plane and have the test done in Shanghai or Taipei by the end of the week. 

In China, if I want an MRI and can afford to pay for one, then who is anyone to stop me from getting what I want? If a cardiologist makes more money for pushing a certain type of stent at a patient, who is going to stop them from recommending it to patients who might do just as well with a less aggressive intervention? 

To be sure, these are problems that exist in many parts of the world, even here. But reviewing the stacks of lab results and CT scans that my patients lug back to Canada from overseas, I can’t help but feel that my patients have stumbled upon the Wild, Wild, West of health care-except it’s in the Far East. 

There is of course a downside when patients straddle two countries for their healthcare. Countless times, I’ve had patients return from overseas after having had a major health calamity. Maybe they had breast cancer diagnosed in China, or a screw placed in their hip after a fall, but now that they’ve returned to Canada, no specialist office will see them.  

Dutifully, the patient brings copies of their hospital notes from China, copies of their CT scans and MRIs, but nobody here is willing to read them because nobody here trusts what the report says. If the documents are written in Chinese, Canadian doctors usually can’t read it. Even if they could and wanted to trust it, can they really do so medico-legally? And so it’s the patient that gets left in the lurch.  

In the end, armed with a Chinese-Canadian dictionary in my early years in practise, or more recently Google translate, I’ve learned to muddle through. With my admin staff translating the documents for me, I can usually piece together what procedure a patient has had done overseas. Then we try to match them with the appropriate follow up here, often repeating the testing and imaging so that patients can access care here. 

But it’s getting better. In my early years, I couldn’t find any oncology clinics willing to follow my patients who had started their chemotherapy overseas. Many of these patients flew all the way here to use their hard-won Ontario health care card, only to have to fly back home shortly thereafter when they realized they weren’t going to receive timely care in Canada. These days, I’ve seen more care handoffs take place here smoothly. Truly, the health care world is becoming a little friendlier to immigrants. 

It used to drive me crazy when my patients sought out health care overseas. In medical school, we’re taught a very idealized version of medical care, something akin to the traditional country doctor’s life straight out of the 19th century. A patient feels unwell. They seek out a local physician. The physician solves the problem or directs them to someone else who can. The problem is solved, and life goes on. 

But in real life, I saw that patients didn’t always stay in one place. Sometimes they asked me for help first. Then they’d go overseas. At other times, they came back from Asia and needed my help deciphering what had happened to them there. And back and forth they went. 

Sometimes I’d get exasperated that they were receiving substandard care overseas. At other times, I’d gain an appreciation that they really could get better, faster treatment for certain things in China that in Canada would have taken ages. In time, I developed a grudging respect for health care in China. 

As I worked with patients who were navigating these two systems simultaneously, I felt myself drawn into a curious, political dilemma. Which health care system is better? 

Sometimes patients would pull me aside and ask me what they should do, fly back to China and seek urgent care or wait a bit longer to see their specialist here in Canada? 

The issues were always some variation of the same theme, a weighing of trade-offs: comfort with the language, wait times, medical expertise, as well as the family support system, all bundled into one massive equation that boiled down to a simple binary question: China or Canada? 

I’ve found my own stance on the issue change over time. When I first graduated from medical school, armed with all my pro-Western biases, the answer was almost certainly Canada. 

But in recent years, I’ve watched medicine advance in China from afar, through what my patients tell me, and through the medical records and histories that they bring back to me. Perhaps there’s still a lot of overkill in investigations on the other side of the ocean, but often the quality of medicine isn’t that different from what it is here. And it’s almost certainly faster. And if you can pay for quicker care, why not? Moreover, many of these Chinese immigrants have family support networks back home that simply don’t exist here. For them to return home for their care simply makes rational sense. Nothing reminds someone of how foreign they are as being in a cold, sterile hospital environment where nobody speaks your language. 

More than a year after she departed, Mrs. Lin returns to my clinic. Following a lumpectomy and ten rounds of chemotherapy, the doctors in China have instructed her to remain on estrogen receptor therapy for the next five years. 

Why did she return to China for medical care? Despite living in Canada for more than a decade and having a passable command of the English language, she still felt that for something as serious as this, she wanted to be someplace she could speak her native tongue. Plus, she would have family members there to support her. Left unsaid is that the entire medical procedure in China took days to arrange not weeks as it would have here. 

I refer her to a medical oncologist, who reports back to me that she is overall, in agreement with the patient’s treatment plan. She replaces the patient’s estrogen treatment with an alternative agent that is available in Canada. 

Web photo by Zac Ong 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 1196

From Tigers to Otaku

09.16.25 2147

The Happiest Couple

07.28.25 1835

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 2437

One Patient, Two Systems 

02.24.25 3142