How Taiwan has confounded predictions in fending off the worst of Covid-19

In the early days of the Covid-19 pandemic, researchers at John Hopkins University predicted that Taiwan would be one of the countries most affected by the virus. It is located just 130km from China, saw more than 400,000 of its 24 million citizens working there last year, and had almost three million Chinese visitors in 2019.

However, Taiwan has defied those expectations.

By the middle of April, Taiwan had still only reported 400 Covid-19 cases, most of which were imported. And just six deaths.

So what did Taiwan do so correctly? Prof Peter Chang is one of the most experienced doctors in Taiwan. Harvard-educated, he was a visiting scientist at the National Institutes of Health, a professor at Taipei Medical University and Kaohsiung Medical University, senior medical advisor to the National Taipei Hospital and now adjunct professor in Tufts University School of Medicine in Boston. He has been an adviser to the ministry of health and has been a health diplomat for the World Health Organisation and the European Union. He also serves as an ombudsman in Taiwan.

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He spoke to The Irish Times about Taiwan's successful approach to limiting Covid-19, discusses what factors were most important in stopping the spread of the virus and expresses concerns about the impact the Coronavirus could potentially have worldwide. He also speaks about his country's tension with China and his reservations about WHO's handling of the pandemic.

Q: How similar is this to virus outbreaks of the past?

A: I don't see any other like this. We had Sars [Severe Acute Respiratory Syndrome] in Taiwan in 2003, but it only happened for several months. And the scale was different because Sars was mostly limited to Asia. Taiwan was the last country to have a Sars outbreak. The difference now is that there are many other countries which are having an epidemic. That makes this very different to Sars.

Q: So how did the Covid-19 situation unfold in Taiwan?

A: Taiwan is really very close to China and we were able to observe China very carefully when it was having this Covid-19 outbreak in very early December. We were suspicious early on and already aware of the situation in late December, although we didn't have any cases ourselves until late January.

We had about one month watching what was going on in China, about one month to be prepared to see if it was going to come to Taiwan. Very early on I was in discussion with the Taiwanese health minister, Chen Shih-chung, about the alert. We exchanged notes quite frequently – “wow, have you heard of that?”, “how are you going to deal with that?”

In January, I was in some discussion with the vice-premier, Chi-mai Chen, too. He is also a physician and we had frequent contact to see what have they prepared. We were watching the situation closely.

That was important as we have Lunar New Year on January 24th. This is a big, big vacation period . . . many people travelled from China to Taiwan. We were aware that it was going to be a big problem, particularly with those coming from Wuhan and the Hubei province.

Q: How much did you know at the time?

A: We didn't have good information, and we don't have a good trust of information coming from China either. But with what happened to China, I think we were the front-runner of alertness. We speak the same language, we have many people living and working in China. And we can read their newspapers too. It was like the Irish people who probably work a lot in London: you know what is going on in London and Scotland. So we know what is going on there.

We are not in a very good way politically (with China), we were in very bad shape with them for many, many years. And so with this neighbour, we are very alert. We are very aware. We probably got a lot of information from individual persons there too, which is beyond government and media. Because the social media in the private sectors is very useful.

So even if we didn’t have all the information we wanted, I believe most of the people in Taiwan already knew something was happening in China last December. Two experts from Taiwan Center for Disease Control visited Wuhan in early January and provided clear alarm. And with the lunar new year approaching, we knew that a wave was coming. We knew the people were returning home, and there could be problems with the virus because of that.

Q: When those people returned from China, were they required to quarantine?

A: Yes, they were asked to self-isolate as soon as we had any suspicions. In the beginning it was those from Wuhan, later in Hubei, and later in more provinces such as Guangdong. When China reported more cases, our quarantine requirements for people coming from those areas became higher. Many, many people were asked to stay at home. They had to really remain immobile. They couldn't leave their apartment or their house for 14 days.

And there were heavy penalties for not following the advice. For example, I know there were cases when those people went out to have a dinner or whatever, and immediately the police would go to visit them. So they would receive a fine. I think there were maybe 20 to 30 cases like this where those concerned got a penalty. That really forced the people to follow the guidelines to stay at home.

Q: So I guess these people were then tested if they showed symptoms during the self-isolation?

A: Yes. Or they would be asked to go to hospital for the testing to be done there. There is something important that I would like to add. We have many people working in China, but are there many people from China staying in Taiwan? That is the question. Well China doesn't like the president of Taiwan, Tsai Ing-wen, who has been in power since May 2016. Because of that, China stopped issuing visas for many Chinese people to come to Taiwan [done in July 2019].That was their political decision. Therefore, we did not have too many Chinese who travelled and stayed in Taiwan last December and January this year. That reduced the early entry of people in Wuhan and the Hubei Province who travelled and brought in virus to Taiwan.

Before Christmas, many rich and middle-class Chinese went out for vacation for Christmas. I would say 800,000 Chinese travelled outside of Wuhan. They went to Thailand, they went to Korea and to Japan and, before the lunar new year on January 24th, they returned home. And they did bring the virus to those places. But much less came to Taiwan, because they were not issued a visa by Beijing. That helped us a lot.

What also helped was the time lag. Because those early travellers didn’t come to Taiwan, the first big risk was the virus carried by Taiwanese coming from China, and that only happened in late January. Those Taiwanese didn’t come back to do shopping at Christmas, because they knew that they would come back one month later in January for the lunar new year.

Had they come back in December, I believe we would have had a lot of community transmission. Very few people talk about that, but I see that as critical. Because the virus is carried by a population, by people. The more people who travel, the higher the risk.

Fortunately in December we didn’t get too many Chinese bringing the virus to Taiwan, and in late January when many, many Taiwanese came back, we had already brought up containment. That gave us one month of preparedness, making us ready for the attack.

Q: And there were limitations on travel from China . . .

A: Well, we didn't close all the borders. We still have five airports to come back from China, but the travel was much less. There were other serious investigations . . . they had to report where they travelled in China and where did they live, so they will be staying at home for two weeks – that is an important quarantine.

Q: Taiwan’s National Health Command Center was established after the Sars epidemic. Has this played an important role in handling Covid-19?

A: Back in 2003, when Sars was a big problem, the health minister at that time (Twu Shiing-jer) was asked to step down. There was a lot of political tension between parties, and when the disease came, they certainly enhanced their argument very much.

Following that resignation and the replacement of the new health minister, there was a problem that the command was not really powerful. The National Health Command Centre was set up in order to be ready to handle another situation like Sars. And the current health minster, Chen [shih-Chung], was really, from the first day, empowered by those in power. But that wasn’t the case at the beginning of the Sars epidemic. There was more political tension then.

I can see that [tension] happening in the United States now – before the election, this is really a good time for big argument. And we were in the same situation in 2003, because in 2004 we had the election. Sars was a big topic for political argument.

We were very lucky this time. We had a general election on January 11th this year. I would say that if we had the election in, for example, in March, and with Covid-19 already coming into Taiwan in January, we would be very much like the United States. Because the political argument really cannot help the health management. We were very, very lucky we already had the national election. I would say that made a big difference.

If you look at Japan and Korea, they are all going to have their elections later this year. They were all having this problem, in terms of politics mixing up with this situation, and sometimes they just cannot do things right. I would say that is an important factor.

Q: What do you consider the most important measures Taiwan has imposed?

A: There were a few. Certainly the experience of Sars was one. It meant we had a history of dealing with a virus like this, and had procedures and a culture and public habits already in place. The second I would say is our national health system, which built up in a very robust way. We have good hospitals, well distributed, well empowered by human resources and they are well accredited. We also have the prior experience of Sars, when hospital transmission shut hospitals down. But now after that, many, many healthcare measures has been improved and revised. All hospitals have to be reviewed regularly by the health ministry.

Many hospitals are also well equipped, including with negative pressure wards. We have about 1,800 of those wards. In Japan it is about the same number, but they have five times more people than us. And Korea also the same . . . because both countries didn’t have Sars. So we learned the lesson very painfully back then, and that helped us to be well prepared this time.

And the third element is very good IT [information technology]. It serves many purposes, including when in early January we suspected lots of people who came in from Wuhan in China. Our security control in the airport can link with the information about the check-ins of those who are coming from Wuhan or Hubei. And when these people come back to our society and if they visit the hospitals, the doctors will be able to easily see who are coming from Hubei or Wuhan in the past two weeks. They can easily understand that they are at higher risk.

That was very true in the beginning. I know the travel history would not work later (because of domestic cases), but in the beginning we checked were these people coming back. And actually quite a few cases were found by this information system. When they were suspected by the physicians, they were sent to the hospital to do the coronavirus test.

So IT was important. Certainly there is an argument about people’s privacy. But in this case, this year, we didn’t have too much arguments about that, because I said that the command was very empowered. There were no arguments. In order to protect the hospitals, we needed to know who are really coming from Hubei and Wuhan recently right from the beginning of the pandemic.

I believe in January that really helped and it worked until mid-February. So even though we had many, many people coming back from China, we didn’t have many cases of coronavirus because of that. That was really the information system helping the hospital to check the travel history. We depended very much on the travel history.

The IT system has also helped in terms of mask purchase. We use the national health insurance card to help the public buy the masks from the pharmacies. Everyone got a quota under that card; you can get two masks a week without any problem. You don’t need to fight for them! And you don’t need to pay a lot, because it is equal. So that also helped.

Q: Why do you believe masks are so popular in Taiwan?

A: In 2003 when Sars happened, there were no people in the airport, the theatre was very much discouraged, and all the people were wearing masks. So there is past experience of using them with a virus.

Culturally, the mask is very popular practice in Taiwan. That’s because there are many people who use motorbikes and scooters for transport, and most of them wear masks to protect from air pollution. It’s part of society. For example, many of my friends, my family, we already have some masks. We have a dozen masks in the house, and some people even have more.

Q: Do you believe wearing them is a good idea in terms of this virus?

A: Well, I think it is comforting for people. I would say the majority of them would say that they don't want to receive unexpected contact with drops of the virus. The others will say they are coughing, so better that they wear the mask to protect others.

It is not an expensive step to take. It is easily accessible, it doesn’t hurt. And people put it on like a uniform. It becomes the culture in our society. I don’t know other countries wearing masks so much, like we do, but it doesn’t hurt and it is easy to practice. And it puts people on alert, without paying too much. It is cheap.

Q: So would you recommend that those in European countries use them?

A: I would say in a close contact environment like a subway, maybe it is not a bad idea. People are within a few centimetres of being mouth to mouth. If someone sneezes or coughs and is spraying a lot of virus . . . the virus may not be Covid-19, it could be influenza, but you certainly could infect a lot of people near you. So having close contact is risky.

Europe and Taiwan are similar in a way. We have the seasonal flu every year, and you do too. But I think the difference is that this immediately brought up a memory of Sars for us. You didn't have Sars in Europe, so you don't experience that learnedness. People here have that memory in the not too distant part.

I would say that wearing masks, if they are affordable and accessible, is not a bad idea. And of course washing hands is very important in the cross [-contamination] phase. I know sometimes it is not easy for you in Europe. In Taiwan it is easy to wash hands, we have sanitiser that people can use in many convenience stores. And in our subways we have free bathrooms where you can do that. But if you go to Paris, you need to pay to go to the bathroom, otherwise you have to go to the restrooms in restaurants.

Our disease control department always encourages people to wash their hands, even without this disease.

Q: If we return to the medical system, I understand Taiwan has a very good national health insurance. It means that people are not reluctant to have health checks as it won’t be a big cost for them . . .

A: Yes, this is an important factor. In Taiwan, we have national health insurance. There is no gate keepers. In Taiwan, the same as Japan and Korea, everyone can visit the clinic 15-16 times per year. People visit because they have good access to hospitals, and really they spend two times more [there] than in Europe. But I would say it is not good. We try to minimise it, but it is hard . . . it is a free market. You can choose where you want. Any time, any doctor, any place. In Taiwan, if you have the insurance card, you visit whomever you like, whenever you like, wherever you like.

It is too much, actually . . . I think we spoil our citizens. Normally it is not good, but at this time we got an advantage, because if anyone had something wrong, they visited the clinic. And if they were referred by the doctor – “wow, this is something different from before, we better send you to the hospital to do the testing”, – they went.

That healthcare system proved very useful in another way. Every year people in the hospital get pneumonia. In Taiwan, before December, loads of people got it and then they were tested for flu, type A or type B flu. They do a quick test, it takes 20 minutes, and the result determines the medication they get.

But in late January the CDC [Centers for Disease Control] health command centre asked all the hospitals to retrospectively check all the people with pneumonia who had been negative for flu A and flu B. They reviewed about 130 around the country in January. The CDC asked the hospitals to test whether they had got a coronavirus. And they picked up three cases because of that.

These three cases would have a lot of contact with other families, their friends, their communities, and we would not be able to know it otherwise. So this retrospective tracing of those people was very helpful.

Q: The virus hit China hard early on and is now worldwide. How has that happened?

A: I'd say that early on, the distance gave a false sense of trust. If the epidemic is far, if the hyper-centre of the disease is far away, people feel, "well, it is not going to come to us". But now people can travel around the world in a few hours.

I can be in Dublin very quickly, right? When I board the airplane I am fine, having a dinner with a friend. He coughs, but I don’t mind. I feel okay, but I might have received the virus already. Then tomorrow morning I might see a friend in a cafe. So within one day the virus has already been carried around the world. And this sense of distance which usually gives us a feeling of being safe is not real.

Q: In retrospect, it seemed that countries could have acted quicker . . .

A: I would say it was very dangerous not to take this seriously. Compared to the 1918 flu pandemic, we know that it reached one-third of the population in the world, and 10 per cent of that died. The USA had much less back then because it is separate to Europe. In China, there were also serious casualties. It is 100 years ago, there were not so many people travelling, you don't spread the virus so quickly.

Now we spread around much faster, there is globalisation, there is so much travel. Certainly airlines are slowing down, but it is too late – people have already travelled. If we knew, we should have had some travel restrictions in December. Maybe we would have been safe, but now it is too late. People are already spreading the virus around the world.

There is a suggestion that 60 per cent of the people will contract the virus. Compared to 100 years ago, we have better medication, better medical services and better hospitals. That is for sure. But we are going to have a lot of contact and a lot more people will get the disease. So are we more healthy than people 100 years ago? I certainly think we are much more healthy, but we also have a lot of old people with morbidities. Many of these people will not survive if they get sick. They are going to be a victim of this.

Governments need to limit large gatherings as much as possible. And for those people with comorbidities, they should not to go to where there are many people. They should stay at home, stay with their families. If they have to go out, wear a mask if it is possible.

Q: Looking at human history, how serious do you consider this virus?

A: I think it is really, really serious. It is like that Spanish Flu. We don’t have such a human damage by any other natural way. Earthquake, hurricane . . . there is nothing like this globally. The virus has really hit us all.

It has really had a big effect on the economy and on social trust. So why is that? Well, we are not surprised by diabetes mortality, we have been used to it. We have many people die from influenza or pneumonia every year, or road accidents. We have more people die from all these things.

But this virus comes as a surprise, and most people don’t know how to treat it. There is no medication so far.

I hope that some good medication will prove to be very effective very soon. For example, I hope that Remdesivir is going to be useful. That medicine was designed for Sars, but Sars ended, so they had no role to play. And in Mers [Middle East respiratory syndrome], a few years ago, it was also supposed to be given by prescription, but again Mers was limited to Korea and a few countries. So the pharmacies didn’t develop it, didn’t manufacture it in a big enough number.

Now they have a good chance for it to be well produced. It stops the replication of the virus, that is how it works. It is in clinical trials at the moment.

But we are still in panic right now because there is no vaccination, no quick tests, no medicine. Nothing.

Q: So do you think there is too much panic, or is it justified?

A: It is real . . . there is real panic from this pandemic. It is real. We haven't seen that for many years. The Dow Jones effects have been very pronounced. And there is no war, right? It is not like someone attacked someone. But we are not used to this new threat yet, the virus. There are widespread effects on economies and I would say it will take about six months for that to settle.

Q: Aside from the economic aspect, do you think the effects of this could ultimately be similar to the 1918 flu, in terms of deaths?

A: I didn't visualise it is going to happen like that, but now I see the United States and Europe, Italy and Germany and now the UK, France and Spain all affected. Even Denmark and Norway. I started to wonder if it is going to be very similar to 1918. But certainly we were not there then, and not many people survived until today. So society has lost that memory. We don't know.

That is the uncertainty, we don’t know if we are going to be like that. But so far it is getting closer to that. If you have 60 per cent of people get the virus, are affected, and 10 per cent get pneumonia and 2 per cent die, then . . . oh my goodness. That would be almost like that. That would be almost like the Spanish flu.

Q: So how do you think this will all finish up?

A: I think it is going to take until next year. Why next year? Because many people will have got affected and got antibodies. If there are antibodies in a big enough percentage of the population, then the disease will stop. And the second chance is that the vaccine will already be available by this time next year. So likely it will take one year from January to next January. And in between then many people cannot overcome the disease.

Q: Finally, Taiwan is not a member of the World Health Organisation. Do you think the fact that Taiwan has handled this crisis so well has strengthened the argument that it should be in the WHO?

A: It is really a big puzzle. We hope to be better off if we can be a member of WHO, to be able to get good information, and to learn what is going on from other countries. We have 70 per cent of our business in international trading, our economy is really 70 per cent with other countries. So we need to know what is going on, in terms of economy, business. But also disease. We have many, many people travelling outside and inside the country. So it is important to learn the best information into infectious diseases. Things usually come very fast, and we are hoping the WHO can be really helpful in that.

But for many years it didn’t work out. The WHO did not favour Taiwan’s participation. The reason is simply because China does not like Taiwan in any international activities. Even though Taiwan follows the international health regulations [IHR] agreement with WHO, even though we can share our disease information with WHO through IHR, communication is still quite limited. It didn’t help too much.

I must say I have concerns about how WHO handled Covid-19. My understanding is that WHO didn’t serve their purpose very much on this case. Their early report only happened on the last day of December. The first report was December 31st, and in early January they reported a new virus. But it was almost one month too late as the virus was already in human transmission in Wuhan in November or early December.

In late December in Wuhan, there were 100 cases of the virus in the hospital. And there were 10 times more people in the community who already had the virus. You could tell that in many, many shops or theatres or whatever, the people working there have the virus already. But WHO had no news at all. The awareness was very low.

I think that for WHO, the alert was really coming in in late January. And they pushed a very low profile. The director general only announced the global international health concern on January 30th when he returned to Geneva from Beijing. And then there is the matter of the WHO executive board meeting. Usually it takes place in the third week of January, but somehow there was a two-weeks delay until February 3rd. It never happened before in WHO history. Who knows what’s the reason for the decision by the director general?

Okay, it was a planned delay, it was not unexpected. But if that had happened as usual in the third week of January, I think it would have put WHO in a place of better preparedness to bring up the issue. On February 3rd, when the executive board meeting happened, the director general was coming back from China and he had to respond to the media and the executive board asking what was going on. And then WHO started to mobilise. So there was also an in-house delay of about two weeks. And I didn’t know why. There was never such a delay before. The alert was almost one month later than it should have been. There is something wrong with WHO, this deserves more attention by international communities.

This Covid-19 is setting an example that even if we were in WHO like you, like the UK or France, countries didn’t get benefit from being a member of WHO.

But, on the other hand, we cannot be so selfish. We are a new democratic country, we are working to be open, transparent, to protect ourselves. We want to know what is going on in other countries.

So what can we do? Can we have a better WHO in the future? And if we can join WHO, I certainly hope we can be useful. Not just with our experience, but also by sharing information.

As I said, we know very much what the Chinese are doing. We are in a good position to know it. We have the same language, we automatically go inside the country. So if Chinese cannot be transparent, we can be useful to the world to provide good information to many other countries.

I would hope we can be useful. Even we are similar in culture, but we run a very different government and politics. I think we have some unique positions, geopolitically. Even Japan is very close to China. Korea too, but we have the advantage to know the culture and language much better. The Philippines is close, but they have a different ideology. Vietnam. we have some similarities with Vietnam, Korea, Japan, but with a different perspective. I see that in every culture they have their own values. This diversity is useful for human beings.

Ireland is a small country but very important. You have the same language as England but different values and history. I happen to know that. So I think diversity is very important. I think it generates good competition. If everybody has the same language, it is very dangerous.

But evolution, biology causes differences because of mutation. And we need differences, we need to change. We are not in a perfect world. This virus is really giving us a good chance to reconsider how we manage the world.