Written by Tsung-Mei Cheng.

Image credit: 總統視導「陸軍第33化學兵群防疫整備」by 總統府/Flickr, license CC BY 2.0

Amidst growing global anxiety over the new coronavirus Covid-19 outbreak that made its debut in Wuhan, China in December of 2019, the Director-General of WHO, Tedros Adhanom Ghebreyesus, said at the news conference in Geneve midweek of the final week in February that “China is showing a decline in new cases.” Figure 1 shows, by day, the number of confirmed Covid-19 cases (depicted in green bars on the horizontal axis) and deaths (yellow bars) in China between January 22 and February 28. However, Tedros cautioned that it is impossible to know how long the decline will last; and pointed to the new and greater concern about what is happening in the rest of the world. As of March 3, confirmed Covid-19 cases are seen in 75 countries, and no one knows how many people are, in fact, infected since many show no symptoms of the disease in its early stage.

As of March 3, there are 11,748 confirmed cases and 213 deaths worldwide outside of China, compared to 3,474 reported cases and 64 deaths just a week earlier. Although these numbers remain far below the threshold for a pandemic, the rate of increase in new cases has prompted the WHO to raise the pandemic risk from “high” to “very high.”

At the same time, the WHO also pointed out that many of the countries with reported cases of Covid-19 also reported last week that they have not had new cases in the past two weeks — for example, Belgium, Cambodia, India, Nepal, Philippines, Russia, Sri Lanka, Vietnam; and emphasized that to date there is no evidence of wide community spread. Macao, which has not had a new case in 23 days, decided that all its public facilities — movie theatres, Karaoke houses, and bars will resume normal operations starting March 2.

Tedros remains cautiously confident that with aggressive, timely measures, Covid-19 can be contained: “This is one key message from China.”

Looking at the rest of East Asia, the Covid-19 situation in Taiwan stands out as quite different from those seen in neighbouring Korea and Japan. Despite its geographic proximity and high level of economic and cultural exchanges with China, as of March 3, Taiwan has only 42 confirmed cases of Covid-19 and 1 death, compared to 287 cases and 6 deaths and school closings in Japan, and 4,812 cases and 28 deaths in Korea.

Taiwan’s response to the Covid-19 threat may explain the differences in these outcomes. It appears that Taiwan’s government has seized the window of opportunity– WHO’s Tedros urged every government to seize and act aggressively and in a comprehensive manner to control, contain, and manage the Covid-19 invasion. Tedros further advised all countries to be prepared for “four scenarios” that can happen at this “decisive point”: “its [Covid-19] first case, its first cluster, the first evidence of community transmission, and dealing with sustained community transmission.”

Taiwan government’s most favoured policy for fighting Covid-19 initially is to prevent it from entering Taiwan in the first place, according to Ming-Liang Lee, former health minister, “Czar of SARS” — commander-in-chief in the debacle against Taiwan’s 2003 SARS epidemic, and now a senior adviser to Taiwan’s President Tsai Ing-wen. To this end, Taiwan implemented strict travel advisories and entry protocols tiered by the risk level of the countries in question. Some examples are as follows: visa approvals for foreigners who had entered or lived in China, Hong Kong, Macao in the past 14 days are suspended. All those entering Taiwan who had transited from airports in China, Hong Kong, and Macao are required to follow the Tier 2 home-based surveillance protocol. Passengers entering Taiwan from Japan, Singapore, Thailand, and Iran are required to observe the Tier 3 14-day self-health management protocol, etc. Table 1 shows a summary of the government’s tiered entry containment-surveillance protocols.

Table 1 Government Protocols for Covid-19 Containment and Surveillance

In addition, all commercial flights between Taiwan and China are suspended except for those to and from four airports in China: Beijing, Shanghai, Xiamen, and Chengdu.

These measures, however, will not entirely prevent the spread of Covid-19 since asymptomatic persons infected with the virus can still infect others. The government also implements a myriad of other measures. For example, the government has adopted a tight “trace contact” protocol to identify, trace, and follow infected, and suspected to be infected, individuals to control and contain the spread of Covid-19. To date, the overwhelming majority of the Covid-19 cases in Taiwan are second, third, fourth or fifth generation infections that predominantly affect the originally infected person’s family members; and Taiwan remains in what Lee calls “a state of limited community spread, because we can trace back the source. Taiwan has been effective in containing the spread of Covid-19 following these policies.”

Despite all that has been put in place to meet the Covid-19 challenge, Taiwan is by no means home safe. Lee acknowledges that it is impossible to predict what will happen in the next month or two since the length of the incubation period of Covid-19 is unknown at this time — estimates range anywhere between a few days to as long as 40 days, with 14 days being the case for the majority of patients. The probability of a community spread is real in Taiwan. The soon to arrive warm and hot weather will help, according to Lee: “The virus does not like the sun and when temperature gets to be around 26.7°C or higher, the virus dies.”

In terms of preparedness for dealing with sustained community transmission, Taiwan may run into a problem. Therefore, Lee is less sanguine about such a prospect. A community outbreak of Covid-19 will call for large-scale quarantine of patients, which in turn will call for a large number of special hospital rooms-beds equipped with negative-air-pressure, along with a large number of health care workers to look after quarantined patients. Taiwan faces potential shortages of both beds and personnel depending on the speed and scale of a community spread. At present two-thirds of the total supply of 1,100 specially equipped hospital beds are occupied by patients with infectious diseases such as tuberculosis. The remaining one-third (300-500 beds) will not be enough to meet the demand in case of a large community spread of Covid-19, according to Lee.

Taiwan also may not have enough medical personnel to care for quarantined patients in such an emergency. Compared to rich countries in the Organization for Economic Co-Operation and Development (OECD), Taiwan has low physician, and also low nurse-population ratios, even for normal times, despite its otherwise high-performing health care system. Figure 2 shows physician- and nurse-population ratios per 1,000 population in Taiwan and comparable OECD countries in 2017. A saving grace is that Taiwan has learned from the SARS crisis that taking care of health care workers is one of the top priorities in any epidemic outbreak.

The government will also consider “borrowing” personnel and beds from military hospitals, or even rent private cruise ships to serve as “floating hospitals” for their ample supply of naturally well-ventilated rooms onboard thanks to abundant ocean winds, which helps “dilute the virus density,” according to Lee.

Noteworthy is the response of Taiwan’s public to Covid-19, which will help see Taiwan through this latest scorch of nature more smoothly. Taiwan’s public has learned from the painful SARS crisis, which saw many dodge the government’s attempts to track, contain and control the SARS virus. Some even ran away from quarantine, which only resulted in harming themselves. The public has been cooperative with the government in combatting the Covid-19 crisis. For example, members of the public willingly come forth to be tested, put in isolation or under surveillance, and follow the government’s home-based surveillance protocols, etc. Handwashing, the most important public health safety precaution in any infectious disease outbreak, since the SARS outbreak has become routine for many Taiwanese as part of their personal hygiene practice. All such measures help in important ways to contain and control the spread of Covid-19.

Ultimately, the outcome of any infectious disease outbreak depends to a significant degree on the response of not only the government but also the public to the threat. Taiwan’s response to date has played an important role in Taiwan’s so far limited spread of Covid-19, despite its geographic proximity and close economic and cultural ties to China, which is the source of the global Covid-19 outbreak.

I would like to thank Dr Ming-Liang Lee for his generous contribution to this article.

Tsung-Mei Cheng is a Health Policy Research Analyst at the Woodrow Wilson School of Public and International Affairs, Princeton University. This article is part of a special issue on Covid-19.

Along with Taiwan Insight’s special issue on Covid-19, we also introduce a timely special issue of the International Journal of Taiwan Studies (IJTS) on “Taiwan, Public Diplomacy, and WHA”. Taiwan’s exclusion from the WHO and the WHA is now a major cause for concern. To understand the reasons, consequences and possible remedies for Taiwan’s exclusion, one has to adopt a multi-disciplinary perspective. In this IJTS’s special issue, we have brought together political scientists, IR specialists, communication scholars, and health experts. For more details, please visit here.