While most of the world suffered through hundreds of millions of cases and millions of deaths from Covid-19, the 23.5 million people in Taiwan largely lived a normal life, thanks to a well-documented strong and early response that saw it go 250 days without a single local case. It lobbied for inclusion in the World Health Organization’s decision-making body off the back of its undeniable success and expertise under the slogan “Taiwan can help”.
But now the tables have turned and the island itself is in need of assistance, after an outbreak that started among airline staff in April spread across the island. The government appears to have been caught short by something it thought would never happen: the poster child for outbreak prevention had apparently failed to fully prepare an outbreak response.
It has so far recorded more than 11,000 cases and 260 deaths, more than 90% of them since mid-May. Affected by inadequate orders, global shortages and geopolitics, it has vaccinated fewer than 3% of its 23.5 million people. The president, Tsai Ing-wen, on Monday gave a broadcast address from her office to assure a population at its second-highest alert level that 750,000 vaccine doses promised by the US would arrive soon.
‘We thought maybe we could contain this’
Multiple health and social experts told the Guardian that as the virus spread in waves worldwide, authorities hadn’t kept up with new scientific knowledge around virulent new strains, the importance of ventilation to combat aerosolised spread, the effectiveness of mass testing, or the examples set by some countries of locking down hard and early. Some felt Taiwan had become “a victim of its own success”, even complacent.
Prof Chen Chien-jen, from the Academia Sinica genomics research centre, says authorities thought they had the pandemic under control with their contact-tracing system and precision testing, but were challenged by the faster spread of the Alpha strain, first detected in the UK, and overwhelmed after a super-spreader event on 9 May – Mother’s Day on the island.
“We thought maybe we could contain this at a small scale, but the virus is really vicious,” says Chen, who was Taiwan’s health minister during the 2003 Sars outbreak and now consults for the government.
Taiwan’s central epidemic command centre (CECC) says it has consulted international experts and governments throughout the pandemic, to build on existing resilience, update its strategies and monitor available resources, but concedes: “While we have been effective in border controls, there is indeed room for improvement in domestic prevention efforts.”
Prof Chi Chunhuei, the director of Oregon State University’s centre for global health, says: “Initially the government was caught off guard, not just by the outbreak itself but the scale, so they are scrambling to mobilise all resources to contain the outbreak, including hospitals and testing facilities.
“One of the issues is most people in Taiwan have been kind of spoiled.”
Chi says 11 months of life as normal and four close calls (a visit by the Diamond Princess, a Taiwanese Navy vessel outbreak, an infected pilot in December, and January’s Taoyuan hospital cluster) left the community and the government “overconfident” in their abilities to contain outbreaks. Even while there was community spread, people packed out restaurants and travelled for Mother’s Day.
Ten days after, on 19 May, the CECCreported 264 new cases and ordered Taiwan into a level 3 alert of a four-tier system, limiting gatherings, mandating public mask-wearing and closing entertainment businesses and schools, but allowing restaurants to continue dine-in services. It encouraged employers to establish working-from-home arrangements but did not enforce it, and did not immediately announce financial supports for remote workers or carers.
A key complication has been the inability to fully analyse trends, due to a backlog of tens of thousands of test results from 169 overwhelmed rapid testing stations and PCR testing processes. Taiwan did not see the need or have the capacity for mass testing.
By late May, the backlog was starting to clear, retrospectively adding hundreds of cases to previous days’ totals and prompting some to question if Taiwan should have gone into stricter lockdown at the time.
“It was so distressing from a data analysis point of view,” said Chase W Nelson, a Taiwan-based computational biologist at Academia Sinica.
“I don’t think it makes things impossible but you have to be careful not to use the revised count in talking about trends because today will always be severely underestimated in comparison to yesterday.”
Back to 2020
Cities around the world have tried what Taiwan is trying – keeping the economy open while imposing restrictions short of a lockdown. For some, like Melbourne, that ended with a damaging and longer lockdown, and the next time they detected community cases they locked down hard and early, for a short time.
But Taiwan’s authorities appear opposed to the drastic measure, and have repeatedly redefined the triggers at which a lockdown would be called.
“Disease prevention and control has its own rhythm, and the stronger the measures are not always the better. We must take public compliance level into account and impose appropriate restrictions to avoid too much harm to society,” the CECC said, adding that moving into level 4 would not necessarily mean lockdown.
Chen says New Zealand – which had several strict but successful lockdowns – is “a good role model” for Taiwan, but “we don’t want to implement the very tight restrictions”.
Prof Yen Muh-yong, the director of the infectious disease department at Cheng Hsin hospital, says there have been major improvements since the outbreak started, but he wants a “traffic signal” segmenting of Taiwan, based on case numbers and risk levels, with according lockdown restrictions.
He says he still has concerns that intensive care units are in danger of being overwhelmed as the number of sick patients grows, increasing the risk of leakage into the community.
“It happened in New York City, and in northern Italy … You have to stop the transmission, so: lockdown. A necessary, well-designed lockdown.”
The current response relies heavily on community compliance but has faltered with a business community intolerant to staff working from home.
The health and welfare minister, Chen Shih-chung, this week angered young people when he said “complacency” had led to rising rates of the virus in their age group. Online, many responded they were more likely to be asymptomatic and were being forced to work in unventilated offices because the government was not mandating remote work where possible.
A growing outbreak among migrant workers who live in crowded dormitories has prompted accusations the government reacted too slowly to protect vulnerable people.
Domestically, hyper-partisanship has also muddied the waters, with several experts telling the Guardian they are wary of publicly criticising the hugely popular government and health authorities, including Chen Shih-chung. One said they felt the government’s aversion to replicating anything seen in China – such as field hospitals or lockdowns – had clouded judgment. For people outside Taiwan or who have closely watched the pandemic, Taiwan today feels unsettlingly nostalgic, as if it is June 2020, not 2021.
The global conversation is now on vaccines, but Taiwan has struggled here, too. “I think the government started thinking seriously [about vaccines] too late,” says Dr Peter Chang, the director general of the Global Taiwan Medical Alliance, and former national ombudsman.
“They thought we were very good with mask-wearing, and people are very disciplined with social distancing, so it is OK.”
Many countries that had early success with the virus have also struggled to obtain and distribute vaccines, but Taiwan faces extra complications, including accusations and instances of geopolitical interference by China. Taiwan alleges that China blocked a deal with the German vaccine producers BioNTech, which China denies.
The CECC told the Guardian it was trying its best to contain the outbreak, but “fair access to effective vaccines is the ultimate solution to bring the global Covid-19 pandemic to its end”.
Japan has delivered more than 1.2m doses and US senators flew to Taipei on Sunday to announce the US’s donation and underscore bipartisan US support for Taiwan.
More than two weeks into level 3 life, case numbers have not dramatically declined and on Monday the alert was extended again, until the end of June.
Chi thinks level 3 is strict enough, and questions the government’s ability to implement anything more than that, but says there isn’t clear enough messaging about how individuals can protect themselves from what he calls “stealth infection” from the high proportion of asymptomatic and pre-symptomatic people.
“You have to assume anyone not living with you in the same household is a potential carrier,” he says. “During the next two weeks or so, don’t have close indoor gatherings with people who don’t live with you.”