How East Asia avoids dependence on immigration

All over Europe, the mantra is the same: “We need immigrants to look after the aged.” Few question it. Birthrates are falling, and people are living longer. The only way to staff our care homes and hospitals, we are told, is to import foreign labour.

But it isn’t. Our dependence on foreign care and health workers is largely a choice. To understand why, you must look at a region usually ignored in discussions of these issues: East Asia.

There are four wealthy, developed East Asian nations that have lower birth-rates, higher proportions of aged, and yet a far lower dependence on foreign workers than Europe. They do have skills shortages, but they are mostly managed internally. They are Japan, South Korea, Taiwan and Hong Kong. (Taiwan and Hong Kong are treated here as independent nations).

All four have long been caught in the demographic vice of low birthrates and a rapidly “greying” population. In fact, East Asian fertility rates are downright catastrophic: South Korea and Hong Kong (and Singapore) are at 1.2, which is close to a voluntary one-child policy, while Japan is at 1.4. Taiwan recently dipped to 0.9, the lowest level in the world. By contrast, the UK is at a relatively healthy 1.8, Germany 1.5 and France 2.0. At the same time, Japan has over 60,000 centenarians, the highest level in the world relative to population. That is a standout figure, but all East Asian nations have high proportions of aged.

So their health systems must be close to collapse and their care facilities paralysed by labour shortages, right? Wrong. I have stayed, and been conveniently ill, in all of these countries. Over the years, I have seen the inside of over a dozen clinics and hospitals in the Far East.

In all cases (except China), service quality was at least equal to the NHS. There are no two-week waits for a routine appointment in East Asia, and no ten-minute time-limits on consultations. It’s hard to compare systems, but it would be fair to call East Asian healthcare semi-private, with social insurance covering most costs, and basic consultation fees at £10-20 for the uninsured. Standards are comparable with anywhere in western Europe. That’s one reason why they have so many old people.

Skills shortages do exist. Care workers are the most urgently needed. Taiwan, for example, already has over 9,000 foreign workers in long-term care institutions alone. (In Japan and South Korea the numbers are much lower). But in all three lands, skilled medical staff are nearly all locally recruited. There is no comparison with what has happened in Britain, where a third of doctors and one in eight nurses were trained abroad, and which has the world’s fifth-highest level of dependence on imported healthcare workers.

Language and cultural barriers

So how do they do it? The answer is a mix of political, practical and cultural reasons.

Fundamentally, public authorities in East Asia do not welcome migrant labour. Usually foreign jobseekers have to go through agencies or state programs, with strict terms and limitations. The immigration processes — getting the work and residence permits, and finding a place to live — are daunting, and they have little prospect of permanent residence. So nurses emigrating from the Philippines, say, would naturally tend to head instead for the more welcoming English-speaking rich countries: the US, Canada, Britain and Australia.  

Another major practical barrier is linguistic. Take for example daily medical notes. “A double dose of Sorafenib” in Tagalog is “dobleng dosis ng Sorafenib.” So a Filipina nurse or care worker would only need basic English to understand this cancer drug instruction. In Chinese, it is “索拉非尼双倍剂量 (Suǒ lā fēi ní shuāng bèi jìliàng).” Similar problems exist with Japanese and Korean. English is not really used in the workplace in East Asia, even in Hong Kong. To read that simple Chinese Sorafenib instruction, a care worker would need maybe 5 years of language study, on top of professional training. The problem is not insuperable; foreign care workers in the Far East are given prior language training. It just takes a lot of time.

Then come the cultural issues. People across the Far East want to be cared for by compatriots, people they feel culturally close to (a freedom that Westerners have been bullied into giving up), particularly in Japan and South Korea. Hospital managements are scarcely less hostile. In a Kyushu University study in Japan a few years back, more than 50 percent of respondents said they “did not desire” to have non-Japanese on their staff or “weren’t sure.” There is also a strong tradition in East Asia of family care of the elderly. This is particularly true in Chinese societies, where country homes will often have a built-in floor for the grandparents.

Finally, it is much easier to get locals to fill care positions because people in the Far East have a better work ethic than say, Brits, and a much greater reluctance to depend on welfare. (Sorry if that gives offence. But it’s true).

For example, in Hong Kong or Japan, retail jobs can pay as little as five pounds an hour (compared with our minimum wage of over eight pounds for over 25s in Britain); still, you rarely see foreigners working in Japanese or Hong Kong shops. Locals have to work, because they cannot expect handouts.

East Asia shows that excessive dependence on migrants is avoidable. Obviously, the cultural factors are hard to replicate in Britain, and we don’t have such a high language barrier. But there is plenty we could be doing: setting stricter terms on migrant hiring, incentivising more people to work in healthcare and removing benefits that encourage idleness. For example, students could pay off part of their debt with a stint in a care home, in routine (unskilled) reception, kitchen and cleaning work, which are a big part of care-home life. It’s just a matter of will.

[To be continued in Parts II and III]

 

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