With conflicting and at times contradictory messages coming out of the White House, the Dow Jones Industrial Average seesawing and even the most basic supplies such as hand-sanitizer in short supply, the United States – a country with a history of helping other nations conquer pandemics – got off to an agonizingly slow start in trying to contain coronavirus.

Wondering what an aggressive pandemic response looks like? Look to Taiwan, says Dr. C. Jason Wang, director of Stanford University's Center for Policy, Outcomes and Prevention.

Following the 2003 SARS epidemic, Taiwan dramatically built up its public health infrastructure to launch an immediate response to the next crisis.

Well-trained and experienced public health officials were quick to recognize the crisis and launched an emergency public health response to contain the emerging outbreak, Wang and colleagues from the United States and Taiwan reported in the Journal of the American Medical Association.

"If you let the fire burn, you could lose control of the critical moment when we could deal with it and put it out faster," Wang says. "The impact is much greater."

An island just 81 miles off the coast of mainland China, Taiwan was a COVID-19 catastrophe waiting to happen. More than 850,000 of the island's 23 million citizens actually live in mainland China. Another 400,000 work there. Last year, nearly 3 million people from mainland China touched down in Taiwan, bringing billions of microbial hitchhikers with them, as travelers always do.

The virus picked the worst possible moment, just days before the Lunar New Year, to shift its base of operations from the animal kingdom into humans. It is a time when millions of Chinese and Taiwanese travel for the holidays. Many stream through Wuhan, the outbreak's apparent point of origin and one of just four major Chinese railway hubs.

Yet, against all odds, Taiwan has remained relatively coronavirus free. As of March 8, the World Health Organization had logged just 45 COVID-19 cases and one death since China notified WHO of the outbreak in late December. Not a single case has been reported in the last 24 hours. China's caseload now stands at about 81,000 with 3,100 deaths.

"It really does speak to the importance of planning," says Jeremy Youde, dean of liberal arts at the University of Minnesota Duluth and an internationally recognized expert on global health politics. "Not just the policy responses, but knowing what kinds of assets we have on the ground."

"We don't suddenly have 100,000 hospital beds lying around that could be used in the event of an outbreak."

How has Taiwan, a country on China's doorstep, managed to contain COVID-19 when so many countries have failed? One answer is leadership, and at the very top. Taiwan's vice president, Chen Chien-jen, is an epidemiologist who received his doctorate at the Johns Hopkins University Bloomberg School of Public Health. He was formerly vice president of Taiwan's premier research institution.

Taiwan learned the hard way – in the SARS coronavirus epidemic in 2003 – what can happen when something goes wrong. For the first couple of months after the World Health Organization posted its first global SARS alert, Taiwan was spared the brunt of the epidemic. The island tallied just 29 probable cases and no deaths and the growth rate was relatively slow, typical of a minor outbreak.

That changed on April 22, 2003, when a cluster of seven infections were reported in Hoping Hospital in Taipei. Desperate to limit the spread of the infection within the hospital, administrators dispersed SARS patients to other hospitals.

Those infections sparked a cascade of local transmissions that culminated in 116 probable cases and 10 deaths in just two weeks, according to a report in the journal Emerging Infectious Diseases.

By mid-May, Taiwan's caseload soared to 264 cases and 34 deaths. By June 1, the outbreak had roughly tripled, reaching 680 cases and 81 deaths, a six-fold increase in less than a month. Ten of the dead were Taiwanese health workers; seven worked at Hoping Hospital.

Subsequent after-action reports laid blame for the massive flare-up on a lack of preparation, mismanagement and carelessness. Taiwanese health officials vowed not to get caught unprepared again. They established a National Health Command Center as the hub of a number of smaller centers charged with responding to epidemics, biological pathogens, bioterrorism and medical emergencies.

The instant Taiwanese officials learned that China notified the World Health Organization of a pneumonia of unknown origin, on Dec. 31, 2019, they sent health workers to board planes from Wuhan and assess passengers for fever or pneumonia before they were allowed to disembark on the island.

Within a week, they expanded their surveillance net to include anyone who had traveled to Wuhan in the previous two weeks. And by Jan. 20, the government activated the Central Epidemic Command Center and charged it with coordinating all government efforts to combat the growing health crisis. In an effort to contain the epidemic, Taiwan employed the most powerful tools at its disposal – big data and analytics.

The country, which has a national health insurance program, was able to link its national health insurance database with its customs and immigration records and quickly identify anyone who entered the country from China and sought medical care. Health officials began testing patients for coronavirus if they had severe respiratory illness and a negative influenza test so they could identify unsuspected cases and anyone with whom the patients might have had contact.

A toll-free number was established so that citizens could report suspicious symptoms or cases. As the outbreak grew, the hotline was overwhelmed and cities were asked to establish their own toll-free numbers.

In a matter of days, the government created a list of 124 "action items," including land and sea border controls, active case finding and quarantine of people with suspected infection and making sure the health system has the resources needed to manage disease.

The government also launched an educational campaign to inform and calm a frightened public and combat misinformation. On the policy front, plans were drawn up for dealing with infections in child care settings, schools and businesses. Taiwanese schools are easier to manage than U.S. schools, because the students do not disperse and rotate from class to class. Instead the teachers rotate.

When a Taiwanese student gets sick, school administrators can cancel the class. If two students in a school get sick, the school closes down. If a third of the schools in the community are closed, all the schools shut down, according to the action plan.

In the U.S., where students travel from class to class, Wang says, "If one student gets sick, the virus has rotated everywhere."

Imposing such stringent measures in the U.S. would be almost impossible, Wang says. The U.S. is vast, geographically, and places public health authority at the state and local level. The federal government must wait for an invitation to launch public health activities at the state level, such as the U.S. Public Health Service "strike team" that was dispatched to Seattle last week.

Making matters worse, the U.S. doesn't have a national health insurance plan – and medical insurance plans don't share their records. It would be next to impossible to do the kind of proactive case finding, contact tracing and surveillance in the U.S. that is central to Taiwan's pandemic response.

The U.S. could, however, mount a far more effective response than it has so far. Wang says.

"The United States has enormous capacity. We have more capacity, more talent, and more money than any place in the world," he says. "It's a matter of recognizing that this is a crisis that needs to be dealt with in a speedy, coordinated fashion."

