Abstract
Taiwan was one of the places most affected by sars in 2003—but one of the least affected by covid-19 in the first year of the pandemic. Taiwan deployed a centralised approach and has been able to effectively eliminate the threat of the spread of covid-19 through swift decisions and effective action. This paper compares and evaluates the Taiwanese government’s emergency responses to two health crises: sars in 2003 and covid-19 in 2020. The policy responses to both are mapped out on easily comprehensible timelines. The study also explores how one crisis governance influences another—how the mishandling of the sars outbreak influenced early governmental responses to covid-19. These are described in more detail, divided into thematic sections, and accompanied by illustrative images.
1 Introduction
covid-19 is an unprecedented transboundary crisis that has gravely affected most countries around the world. Taiwan has enjoyed normalcy throughout the whole first year of covid-19—with only 911 cases of infection and eight deaths by 1 February 2021. Citizens were able to go to restaurants and bars, travel around the country, and attend concerts and festivals (Figure 1). The country was virus-free, meaning no locally transmitted cases from April to December 2020 and then again from January to April 2021. At the end of 2020, local clusters of infection appeared—due to flight crews and frontline medical workers—but Taiwan soon managed to stop the spread, as the army was deployed to disinfect markets, restaurants, and other locations that those infected with covid-19 may have visited. Another, slightly bigger outbreak of covid-19 transmissions appeared in May 2021,1 and numbers rose dramatically (by Taiwan standards)—15,618 cases of infection and 789 deaths by 1 August 2021.2 However, new cases per day have fallen from their peak of 535 on 17 May to an average of about 10–20 per day in July. The pandemic is not over at the time of writing, and Taiwan will have to work hard to keep the numbers low.
Crowds of people attending pride 2020, while most of the world was under lockdown.3
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
There have been many speculations about the reasons for Taiwan’s success in its handling of the pandemic during its first year—for instance, was it due to Taiwan’s political system, the fact that it is an island, or owing to Taiwan’s relatively small population? None of these factors provide a satisfactory explanation since there are many other democratic societies, islands, and small countries that have severely been affected by covid-19. What explains Taiwan’s success are the lessons learned from earlier health emergencies, most notably severe acute respiratory syndrome (sars) in 2003.
sars was initially considered a problem that was confined mostly to Hong Kong, and the Taiwanese did not take any urgent steps until an outbreak at the Heping hospital in Taipei in April 2003. Health officials ordered a complete lockdown, with all the staff having to remain in the hospital for a mandatory quarantine. During these two weeks, 57 staff members were infected and seven died; 97 other people trapped in the hospital were infected and 24 died (Chun, 2021). This incident caused an even wider epidemic throughout the island. It was eventually contained—once the health officials introduced mandatory quarantines, body temperature screening at airports, special facilities to treat infected people, and widespread disinfection measures in hospitals—but the response was slow and clumsy. sars created a nationwide panic which stemmed from the mishandling of the crisis, but it also led Taiwan to prepare for similar crises in the future. Many people credit Chen Chien-jen, the former vice president (2016–2020), who is also an experienced epidemiologist, for preventing the spread of covid-19 in Taiwan. He played an important role by the end of and after the sars crisis as minister of health (2003–2005), pushing for a series of reforms to prepare the island for future epidemics (such as, building isolation departments and research laboratories).
Consequently, in 2020 Taiwan showed strong top-down governance in centralising the coordination and distribution of resources and release of information (Chun, 2021). The government responded quickly and managed to avoid imposing a lockdown (meaning, restricting access to public facilities and services, in some instances even imposing ‘stay-at-home’ orders, as has been the case in many countries around the world). Within the first two months, it implemented more than 100 actions, including border control, travel restrictions, proactive case finding, imposing quarantine, resource allocation, communication, and fighting misinformation (Wang, Chun & Brook, 2020). Thanks to these coordinated, timely, and effective actions, Taiwanese people did not experience the orders to ‘stay at home’ or work from home that were so common in many parts of the world.
Additionally, besides the government’s capacity to maintain citizens’ trust, the negative sars experience fostered a discourse of interdependence (Lo & Hsieh, 2020)—blurring the boundaries between individual and civic—and increased people’s willingness to comply with the policies, and most notably digital bio-surveillance, which ultimately also helped to limit the covid-19 crisis in Taiwan (Figure 2).
How sars influenced the handling of the covid-19 crisis in Taiwan.
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
This study compares and evaluates the Taiwanese government’s responses to sars in 2013 and covid-19 in 2020. The policy responses are mapped on easily comprehensible timelines. The study also explores how one crisis influenced the other—how the mishandling of the sars outbreak influenced early governmental responses to covid-19. For this study, Chinese- and English-language government releases as well as news articles have been consulted, combined with first-hand experience. It is organised as follows: in section 2, Taiwan’s experience with sars is described. This is followed by an analysis of Taiwan’s response to the current pandemic in section 3—divided into thematic subsections. Section 4 contains a comparison of both responses—with a timeline, as well as the lessons learned that influenced future crisis management in the country. Finally, the conclusion sums up the findings of this research.
2 Taiwan’s Experience with sars
Taiwan was able to respond quickly and effectively to the covid-19 pandemic thanks to its experience with sars. In 2003, sars caused panic in Taiwan due to the government’s slow action and overall mishandling of the initial (and most crucial) phase: the health authorities eventually adopted a draconian quarantine policy, but mainly as a political tactic to contain the widespread hysteria (Chun, 2021). This experience ultimately led the country to prepare for similar health crises in the future.
At the turn of 2002 and 2003, there were a number of cases of sars in Taiwan, caused by a coronavirus called sars-associated coronavirus (sars-CoV). These were accompanied by influenza-like symptoms and others similar to those of covid-19 (who, 2019). sars began to spread in November 2002 in the Chinese province of Guangdong (who, 2003e). The People’s Republic of China (prc) did not officially inform the World Health Organization (who) of the spread of this atypical pneumonia until 11 February 2003 (Figure 3), when 305 infections and five deaths were recorded (who, 2003a). Among the first countries in which human-to-human transmission took place was Taiwan (who, 2019). The global epidemic lasted for several months, with the last chain of patients interrupted on 5 July 2003. In total, the sars epidemic affected 29 countries, 8,422 people fell ill and 916 died, out of which 5,327 infections and 349 deaths were confirmed in the prc, and 674 infections and 84 deaths in Taiwan (who, 2003a). Since then, sars has reappeared three times, all due to laboratory accidents (who, 2004). In the first case, a laboratory technician became infected in Singapore during the handling of the West Nile virus, which was contaminated with the sars virus (who, 2003b). A similar situation occurred in a Taiwanese laboratory, where a lab technician was exposed to sars samples (who, 2003c). In the prc, two researchers were infected in a laboratory in Beijing, also during sample handling (Walgate, 2004).
Timeline of initial responses to sars in 2003.
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
Taiwan confirmed the first case of sars on 10 March 2003 (who, 2019). According to a who analysis, the spread of sars in Taiwan had two main phases. The first took place before 19 April: 78 percent of the cases had been imported, 16 percent had spread in households, and 6 percent had originated in hospital facilities. In the second phase, from 20 April to 16 May, up to 89 percent people got infected in hospitals, 9 percent had a travel history, and 2 percent fell ill due to community spread (who, 2003a). The rise in the numbers of infections was due to Heping hospital in Taipei, in which a hospital worker tested positive and the disease then spread. In connection with this, another eight hospitals recorded cases of infection, which included many healthcare workers (cdc, 2003).
A 10- to 14-day quarantine was introduced at two levels: level A quarantine had to be completed by all close contacts of the infected, and this was introduced on 18 March. In the case of the level B quarantine, people who arrived in Taiwan from areas where sars was confirmed, such as the prc, had to be placed in isolation. This type of quarantine was introduced in response to the first sars death in late April. The care of those in isolation was provided by the state using nurses, who helped with tasks such as pet care, laundry, and food delivery (Hsieh et al., 2005). In addition, quarantined people were required to measure their temperature three times per day and then report it to the nurses by telephone (Chen et al., 2005). More than 55,000 people underwent level A quarantine, and more than 95,000 underwent level B. Of the total number of quarantined people, the infection was later confirmed in only 17 subjects, while the presence of antibodies in the blood was found in seven (Hsieh et al., 2005). Starting in June 2003, these measures were relaxed, and Taiwanese people working in the prc could return to the country without undergoing quarantine, on the condition that they wear a face mask.
A month after the first case in Taiwan (21 January 2003), the government introduced mandatory body temperature screening at airports, with the regulation covering both outgoing and incoming passengers. If a passenger had a temperature higher than 37.5 °C, they had to undergo a medical examination (Chen et al., 2005). In addition, passengers arriving in Taiwan were required to complete a health declaration during the flight (tcdc, 2014).
Moreover, the Ministry of Health and Welfare identified approximately 100 clinics that were able to screen potentially infected patients to prevent the spread of the disease to emergency rooms (Schwartz, 2009). At the beginning of the epidemic, hospitals were prepared to treat infected patients in negative-pressure isolation rooms—with a total of 764 such rooms available during the first two months.
At that time, the who recommended wearing protective equipment along with proper hand washing (Twu et al., 2003). Widespread disinfection measures were also introduced in hospitals. People had their temperature measured at the entrance to each hospital, and everyone who entered or left had to wear a face mask or respirator. In bigger hospitals, corridors were set aside for patients with sars, who were also moved to their wards using elevators reprogrammed to deny access to other areas (Esswein et al., 2003).
The last case in Taiwan was recorded on 15 June. With 674 cases and 84 deaths, Taiwan was ranked in the top three most-affected countries/regions in the world, along with the prc and Hong Kong (who, 2003d). A month later, the who removed Taiwan from the list of sars countries.
Ultimately, about 90 percent of the sars cases originated in hospitals, which was also reflected in the political reaction. In May, the health minister resigned due to the ineffective diagnosis procedure and subsequent failure to isolate patients and was succeeded by Chen Chien-jen (voa News, 2003), who was vice president at the start of the covid-19 epidemic, and a qualified epidemiologist. This resulted in restructuring and improving the efficiency of the hospital system, which Taiwan benefited from during the covid-19 crisis.
3 Taiwan’s Response to covid-19
While multifaceted, Taiwan’s quick and effective response to the covid-19 pandemic falls back on the negative experience with sars outlined in the previous section. Specific components of Taiwan’s initial response to the pandemic are discussed in this section.
As soon as the information about an atypical pneumonia in Wuhan appeared—on the last day of 2019—Taiwan’s Centers for Disease Control (tcdc) contacted the who as well as its Chinese counterpart requesting confirmation of the infectious nature of the disease (mofa, 2020). Taiwan’s administration in charge of prevention, surveillance, investigation, and control of communicable diseases under the supervision of Ministry of Health and Welfare received a lacklustre response explaining that the who would deal with this request, but nothing more (Everington, 2020a).
Nevertheless, Taiwanese authorities acted right away (Figure 4). Quick action on the border effectively isolated Taiwan and prevented the import of more potentially infected people. A smart move was also the linking of existing databases to create an early warning system. The government-imposed quarantines and a digital surveillance system to trace contacts and prevent violations of the quarantine rules. Moreover, it allocated special facilities for testing and for caring for patients—this avoided frustration and confusion over which hospitals would take in infected patients. To avoid shortage and price manipulation of masks, the authorities banned their export and introduced an allocation system. Besides these more technical measures, the government also communicated very frequently and effectively —fostering trust in it among the public.
Timeline of initial responses to covid-19 in 2020.
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
3.1 Travel Arrangements
On 31 December 2019, already alarmed by the situation and with a lack of information from outside sources, Taiwan introduced checks on passengers arriving from Wuhan—the first country to do so. Passengers were required to complete a health declaration and tcdc officials conducted onboard screenings on each of the 12 direct flights from Wuhan each week (mofa, 2020).
Special travel arrangements were then extended from people arriving from Wuhan to those coming from Hubei, Zhejiang, and Guangdong provinces. By the end of January 2020, the entire prc, including Hong Kong and Macao, was included on the list of high-risk areas. Passengers arriving from China who showed signs of the illness were referred to a designated hospital for evaluation. People arriving from other high-risk countries had to undergo a 14-day quarantine (Cheng et al., 2020).
Travel-related controls were introduced in two phases. The first began with the aforementioned measures introduced on 31 December 2019—leading to a total ban on entry from the prc on 11 February, including suspending all tour groups to and from China, and suspending many types of visitor permits for Chinese nationals (mofa, 2020). In the second phase, Taiwan focused on the potential risk of importing the disease from other countries, dividing them into three groups based on the risk posed: Watch Level 1 (Green), Alert Level 2 (Yellow), Warning Level 3 (Red) (tcdc, 2020a). Very soon, all countries around the world would be identified as high risk (level 3) since most cases of infection were imported from abroad (Lin, 2020). On 19 March 2020—the day when the number of infected people reached 100—Taiwan banned entry for foreigners, excluding resident permit holders, diplomats, migrant workers, and people with special permits (Garda World, 2020). The last step was banning flight transfers in Taiwan (Reuters, 2020). With this, the country was effectively isolated from the outside world until summer 2020.
3.2 Quarantine and Digital Surveillance
The new virus—then known as severe infectious pneumonia—was classified in the fifth category of infectious diseases with an obligation to notify the authorities. If people suspected they were infected, they were required to report this to the health authorities within 24 hours. After reporting, they were to be subjected to a quarantine, tracing of nearest contacts, epidemic examination, and treatment (tcdc, 2020a). Taiwan initially focused on establishing an effective system that would quickly allow identification of new cases, restrict their movement, and find people who had been in contact with the infected person. The government decided to use the national health insurance database, which it merged with the immigration and customs database. In the event that a person suspected of having covid-19 visited a doctor, the system generated an immediate warning based on a combination of symptoms and travel history. In addition, a covid-19 phone line with the number 1922 was introduced, where people could inquire about covid-19 and report if they suspected themselves or even others may have contracted the virus (Wang, Chun & Brook, 2020).
From mid-February 2020, people entering Taiwan had an obligation to fill in health declarations on an online platform through their smartphones. The system also included scanning of a qr code and a subsequent sms, without which border crossing was not permitted (Huang, 2020). The elimination of risk in connection with the declarations was supplemented by a three-level system. If passengers arrived in Taiwan from level 1 and 2 countries, they were sent a confirmation sms and could pass the border control. However, if they arrived from a high-risk level 3 country, they were obliged to start quarantine in a home immediately after arrival (Wang, Chun & Brook, 2020). In March, these measures were tightened, and all visitors had to undergo a 14-day quarantine (at home or a government-approved quarantine hotel), followed by a seven-day self-health management programme, since all countries were identified as extremely risky (Lee, McCauley & Abadi, 2020).
To make sure people were actually following the quarantine measures, the tcdc (in collaboration with Taiwanese operators) set up a system to track people on their phones, the Home Quarantine E-System. This system used triangulation of the location of phones relative to nearby cell towers rather than gps tracking. Although it is not as accurate as gps tracking, the government claimed that it was less of an invasion of privacy (Eigen, Wang & Gasser, 2020).
At the beginning of the quarantine period a package (Figure 5) containing a thermometer, face masks, and snacks was delivered by the local authorities. These packages varied greatly, depending on the township and type of quarantine—home or hotel. Each day, people in isolation received a phone call enquiring about their health status. Besides the calls, there were also automated smss that needed answering (free of charge) with the number 1, 2, or 3 depending on the recipient’s health (Figure 6).4 In the event that the quarantined person did not pick up the phone, or had left their quarantine location—in the latter case an automated text message notifying them to return to their location was generated—the relevant government authorities (ranging from the local police precinct to local city government) were immediately notified (Su, Yen & Yang, et al., 2020). Violation of the quarantine could thus result in a confrontation with the police, who were able to arrive at the person’s place of stay within one hour of receiving the notification. The system proved to be quite effective, although there were many unnecessary police visits due to low phone battery or poor network signal. Moreover, quarantine violations could be fined to up to nt$ 1 million (c. US $33,000) (Lee, McCauley & Abadi, 2020). By October 2020, fewer than 1,000 fines had been given in relation to breaking the quarantine, and thus there was a 99.7 percent compliance rate (Wang, Ellis & Bloomberg, 2020).
Packages delivered to quarantined persons by the local authorities. (a): hotel quarantine in Guishan (Taoyuan); (b): home quarantine in Zuoying (Kaohsiung).
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
Automated sms during and after the quarantine period.
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
The above-mentioned primary recommendations were issued by the Central Epidemic Command Center (cecc, which was involved in the fight against sars), composed of the Department of Health, the Ministry of Interior, the Ministry of Foreign Affairs, and the Ministry of Economic, and medical experts in cooperation with the tcdc. Based on their guidance, the government ordered the two most important measures, the digital surveillance system and quarantine (Weinstein, 2020).
However, the surveillance system was not new. Already in 2017, the tcdc created the trace platform—inspired by the Ebola epidemic in Africa. The platform enables contact tracing and is applicable to various types of diseases. In mid-January 2020, it was adapted for covid-19 (Jian et al., 2020). It links 20 to 30 contacts per confirmed case, and each one must undergo a 14-day quarantine (Marmino & Vandenberg, 2021).
The government-controlled digital surveillance system raised the question of whether and to what extent such surveillance is acceptable in a democratic country. Taiwanese people call it the ‘digital fence’, but still seemed to prefer surveillance over the threat of the pandemic. The high compliance with digital surveillance in Taiwan was at first explained by the country’s authoritarian past and the cultural legacy of Confucianism, although these explanations have now been debunked. A much more likely explanation for the high compliance of the Taiwanese people with the measures in place to curb the covid-19 pandemic has to do with the (negative) experience with health emergencies in the past, namely the sars outbreak in 2003.
Moreover, Taiwan was not the only Asian country to respond to the pandemic with very strict prevention measures including a digital surveillance system. In Singapore, the authorities built an application that helps keep distance between people through a Bluetooth signal. In addition to an app, Hong Kong introduced the mandatory wearing of a tracking bracelet during quarantine. In South Korea, a mobile application helped locate those infected in relation to others (Huang, Sun & Sui, 2020), while Myanmar had its Saw Saw Shar app, Thailand Thai Chana and Mor Chana, Brunei BruHealt, Indonesia PeduliLindungi, and Laos LaoKYC, to name a few (Asia Center, 2020). What they all had in common is that many users expressed concern about giving access to the entire phone to the developer (and possibly to the government), while Taiwan has had very little discussion on this issue.
3.3 Hospital Preparedness and Testing
As soon as the prc reported on the new disease, infrared body temperature screening systems and hand sanitisers were installed at the entrances of Taiwanese hospitals (Liu, Hsu & Lin et al., 2020). At the same time, hospitals created a system of separate entrances and exits from buildings, with some entrances intended for potential covid-19 patients and the others for other visitors. Persons with suspected or confirmed covid-19 were treated in separate parts of the building, away from the emergency room and other inpatients. The government also advised people to replace visiting loved ones in hospitals with video calls. While some hospitals, especially paediatric and maternity hospitals, banned visits altogether, others followed the tcdc’s recommendations on the number and frequency of visits. In addition, the government ordered the wearing of face masks for all visitors to hospitals, including staff.
The government was fully aware of the threat faced by paramedics on the front line—the lack of which could lead to the collapse of hospitals in the event of infection spreading. To prevent the spread of the virus, it initiated the distribution of surgical masks to all local hospitals and clinics. Each healthcare professional received one or two face masks per day, and caregivers caring for covid-19 patients were provided with additional masks or respirators. The government also provided face masks for high-risk groups, such as patients with cancer undergoing chemotherapy, radiotherapy, or haemo dialysis (Chang et al., 2020).
In mid-March 2020, the tcdc was preparing for mass testing and eventual hospitalisation of the infected and thus 167 facilities were allocated for testing and another 50 for caring for patients (mofa, 2020). However, unlike most countries in the world Taiwan did not eventually carry out mass testing, as the tcdc concluded that a 14-day quarantine and subsequent seven-day self-health monitoring were sufficient. Although there are many cases of community-based spread of the disease in the world due to the infection being spread by asymptomatic people, tcdc noted that this often happens due to quarantine violations (tcdc, 2020b). For example, as of 30 September 2020, Taiwan had tested a total of only 194,729 people—less than 0.01 daily tests per thousand people (tcdc, 2020c), while Australia, with a population of 1.6 million more than Taiwan, performed 7,637,403 tests—1.36 daily tests per thousand (Australian Department of Health, 2020; Our World in Data 2020).
3.4 Face Mask Allocation
Prior to the start of the pandemic, Taiwanese face mask manufacturers were able to produce 1.88 million masks per day, rising to 2.44 million if necessary. The government wanted to avoid a shortage of face masks in the country, as well as avoid a scenario where prices could be forced up. In January 2020, the government issued an official ban on the export of masks. In addition to Taiwan, other countries also introduced a ban on the export of face masks between February and April, namely South Korea, Thailand, France, Germany, and Russia. The Taiwanese government also ordered the redistribution of all domestically produced face masks, a daily total of about four million masks (Su et al., 2020), and shops selling various goods, such as 7-Eleven convenience stores, were suddenly forbidden from selling face masks.
The National Health Insurance (nhi) administration then created a plan for the distribution of masks, under which the masks were sent to 6,505 contracted pharmacies and drugstores, and on 6 February a name-based rationing system was launched. Residents who wanted to buy a face mask had to identify themselves with their nhi cards at the points of sale (tcdc, 2020d). Each buyer could buy a maximum of two masks per week. The rationing system was not limited to locals, as foreign visitors also had access to face masks, including students and migrant workers, who had to prove their identity with an id (passport or a residence permit) (Everington, 2020b). To reduce the risk of the spread of the disease and avoid the creation of places where a larger number of people could be concentrated, customers were divided into different days—those whose nhi card ended with an even number could come and buy masks on Tuesdays, Thursdays, and Saturdays, while those with an odd number could come on Mondays, Wednesdays, and Fridays; and everyone could buy masks on Sundays (tcdc, 2020d). Due to the growing demand, from March people were allowed to buy three masks per week for adults and five for children. At that time, the production of face masks already averaged almost 8.2 million per day (tcdc, 2020e). The government guaranteed not only an even distribution but also affordability. For example, after starting the sales phase, it was possible to buy a mask for just nt$ 5.00 (c. US$ 0.17).
In early April, the who also called on countries around the world to increase face mask production (Su et al., 2020). With a production capacity of 13 million face masks per day, Taiwan decided to donate a total of 10 million face masks—seven million to Europe (primarily Italy, Spain, France, Germany, Belgium, and also the UK), two million to the US, and the remaining one million to smaller countries that have diplomatic relations with Taiwan (S. Chen, 2020). Taiwan’s international efforts were branded as ‘Taiwan can help’. In this political campaign, President Tsai Ing-wen emphasised the importance of international cooperation to stop the spread of covid-19. By May, daily face mask production capacity increased to 20 million, and in the second half of July the government decided to donate another batch of masks, a total of 51 million pieces to 80 countries (J. Chen, 2020).
The initial ban on face mask exports provoked a wave of criticism on the part of both the prc and the opposition Kuomintang party (kmt). Later, when Taiwan decided to donate masks to the US, the prc again expressed its opposition, calling Taiwan’s ‘flattery’ of the US more harmful than the virus itself (Rowen, 2020). The reason for the kmt’s negative attitude towards the export ban was its argument that it only applied to the prc, although in truth it applied to all countries. The ktm also criticised the government for failing to provide assistance to Wuhan, which needed it the most at the time (Woods, 2020).
3.5 Communication and Politics
While successful crisis management requires governance capability—preparedness, coordination, risk assessment, implementation, and so forth—which Taiwan has demonstrated it disposed, the authorities also need legitimacy to maintain the citizens trust towards the government. This has been achieved by extremely effective communication. As a global leader in e-government, Taiwan put transparency at the centre, with vast open-access data repositories made available through the tcdc and government websites.
At first, the media in Taiwan treated the unknown disease as an enemy and spoke of a war, warning the public of the seriousness of the crisis. The government then communicated with the public very openly and gained people’s trust. It also announced every new case to the public, including the detailed travel history of the person in question and other relevant details (without giving away the identity of the affected people). Cases were divided into imported and domestic ones (Figure 7). This meticulous reporting has been kept up also when the numbers spiralled out of the two-digit numbers in May 2022. In addition to the health minister appearing every day on tv to report on the situation, becoming quite a star in the process, people could also sign up via the line app for prompt updates on the situation. Moreover, the government engaged in misinformation management—using press releases to correct false information as well as stating the legal consequences for spreading it, with offenders being fined up to nt$ 3 million (US$ 99,648) under the Communicable Disease Control Act (Lee & Chung, 2020).
How covid-19 cases were reported in Taiwan (on 22 December 2020 there were three imported cases and one locally transmitted case).
Citation: International Journal of Taiwan Studies 6, 2 (2023) ; 10.1163/24688800-20221249
Frequent and effective communication created greater trust in the government, which significantly affected people’s compliance with the policies. Besides the fear caused by a negative past experience with a health crisis, sars, trust might also be the reason why so few people expressed concerned over the digital surveillance, essentially bio-surveillance. Moreover, criticising the surveillance system was tantamount to criticising the government at this point, and anyone who did so was immediately attacked by pro-government figures or the government itself.
4 Comparing Taiwan’s Responses to sars and covid-19
This section compares Taiwan’s initial response to sars and to covid-19. In 2020, Taiwan was much faster and better prepared thanks to going through the sars epidemic in 2003. Back in 2003, Taiwan was not well positioned in emergency preparedness. Moreover, President Chen Shui-bian (dpp, 2000–2008) presided over a deeply politicised society with low levels of public trust and a high level of public dissatisfaction. In 2020, although already excluded from the who (since 2016), Taiwan’s response was exemplary (Y. Chen, 2020).
The sars and covid-19 coronaviruses are biologically very similar. With sars there was a higher global mortality rate, of 11 percent, while that from covid-19 is 4.2 percent (Hu et al., 2020). However, an important difference between the viruses is the fact that covid-19 is many times more contagious and easily transmitted (Petersen et al., 2020). Table 1 shows some of the differences in how Taiwan reacted in the first months to these crises.
In the case of travel measures, the country reacted faster in 2020. The first case of sars was recorded in Taiwan 27 days after the prc already reported the infection, while the first covid-19 case was 21 days later. While airport temperature screening was introduced for sars 31 days after the outbreak in Taiwan, for covid-19 the country responded before the first case was even recorded, immediately on the day the prc released news of the new virus. In the first phase of sars, when most of the infected were people arriving from abroad, the country did not completely shut its borders as it did in 2020. On 19 March 2020—the day when 100 people had been infected—foreigners (with some exceptions) were banned from entering Taiwan.
Back in 2003, a compulsory quarantine was introduced on 18 March for those suspected of having sars as well as their close contacts, but it was not until more than a month later that this was applied to all people arriving from high-risk areas. Thus while the number of those infected increased, the elimination of the primary risk came relatively late. With this lesson learned, during the covid-19 crisis Taiwan introduced quarantine measures just 15 days after the initial measures at airports, as well as the obligation to make a report in cases of suspected infection. The procedures for monitoring the status of people with symptoms were similar for both diseases, although more technically advanced and sophisticated by the time of covid-19.
In terms of hospital readiness, the government also acted slowly (or slower) in 2003. Although several facilities were equipped with negative-pressure isolation rooms, the equipment inspection (and thus the discovery of deficiencies in hospitals) did not begin until mid-March. Within a similar timeframe—in the first months after the outbreak of covid-19, hospitals along with treatment and testing sites had been identified, and this time they were much better equipped. While in 2003 Taiwan had more than 700 negative-pressure units ready in the first months, in 2020, 2,000 such units were prepared along with another 20,000 beds for patients with mild symptoms in hospitals across the country (Khaliq, 2020).
Taiwan was one of the places most affected by sars in 2003. The illness spread together to 29 countries, where more than 8,000 people got sars and 774 of them died. In the United States, only eight people got the illness and none of them died. In Taiwan, however, the mortality rate was the highest. This was due to the spread of the disease in hospitals during the second wave of the epidemic. In just one hospital in Taipei 154 cases and 31 deaths (out of a total of 37) were recorded (Khaliq, 2020). As the country was not prepared for this type of infection, and information about the disease was scarce, people were panicking (Chung & Chou, 2020). This resulted in disquiet among healthcare workers who feared for their safety while performing work-related tasks, and many considered resigning.
This widespread fear affected people’s mental health, which led to the launch of a Computer Psychology Clinic providing free mental health services in 2004. To avoid the same situation in 2020, the government asked a number of psychologists and psychiatrists not to travel abroad and instead to help cope with the pandemic if and when needed. During the first year of covid-19, however, there was no mass panic or sense of helplessness in the country, at least not to the same extent as during sars.
Some hospitals had to be completely closed due to infections, while others refused to admit patients with symptoms due to their concerns. This resulted in a reduction in the credibility of the healthcare system in the eyes of the population. The chaotic system of transferring those who were suspected of being infected between hospitals was also perceived negatively, as they were forced to visit various facilities on the basis of medical recommendations (Kao et al., 2017). The number of hospitals was also a problem. In 2003, patients with sars were treated in only 15 designated hospitals; in contrast, dozens of hospitals were designated to treat people infected with covid-19.
Following the sars epidemic, the Taiwanese government invested heavily in the tcdc, hospitals, and infectious disease laboratories to increase their capacity. This paid off because as soon as more information on the genetic character of covid-19 was available, Taiwanese laboratories began working on the development of a testing method and rapidly increased the capacity of the tests performed through a network of 37 facilities that could, at that time, perform 3,900 tests per day (Han et al., 2020). Moreover, the country had personal protective equipment readily available as a result of stockpiling it after sars in preparation for another respiratory virus.
In addition to investing in these sectors, in 2004 the government established the National Health Command Center, a disaster management centre, responsible for action and responses to future infection outbreaks. The Center activated an expert advisory panel, the above-mentioned cecc, in January 2020 (Duff-Brown, 2020). Once an epidemic occurs, the cecc is given the highest national authority and the power to integrate information and coordinate every ministry—it helps to effectively mobilise government funds, military personnel, and medical resources for disease control actions (Yeh & Cheng, 2020). It is this department that is behind many of the regulations and precautionary measures that have been gradually applied by the tcdc in the wake of the pandemic in Taiwan. In addition, it also worked to continuously educate the population through online videos about covid-19 (Chung & Chou, 2020).
Today, Taiwan is one of the places least affected by covid-19. It is becoming a model for many other countries that have been hit hard by the pandemic, although its experiences are not replicable everywhere. Thanks to going through a similar situation in 2003, Taiwan was well prepared and determined not to allow the scenario to be repeated or get even worse, and it reacted quickly and quite aggressively in terms of measures. At the same time, however, it was also successful thanks to its citizens who, based on previous experience, were motivated to comply voluntarily.
5 Conclusion
Taiwan was one of the places most affected by sars in 2003—but one of the least affected by covid-19 in the first year of the pandemic, without having had to impose any form of a lockdown (however, tight restrictions on daily and social activities, including an entry restriction to foreigners to Taiwan followed the spread of the virus in May 2021).
Taiwan deployed a centralised approach and thanks to lessons learned from the mishandling of sars in 2003, it has been able to effectively eliminate the threat of the spread of covid-19 in 2020 (and partially also in 2021) through swift decisions and effective action. The sars fiasco resulted in efforts to restructure and improve the efficiency of Taiwan’s health system, which Taiwan benefited from during the covid-19 crisis.
In the successful handling of the covid-19 crisis, one of the most important factors was the timely implementation of measures immediately after the suspicion of a sars-like disease on 31 December 2019—onboard screenings, quarantines, and flight bans. Taiwan has taken a different path than most other countries in the world which have focused on mass screening and relied on quarantines and heavy fines instead. In the next step, the authorities linked databases and created an early warning system along with a digital surveillance system—besides time, also digital efficiency and preparedness played an important role. Also, special facilities for testing and patient care were allocated and masks rationed—this way avoiding confusion and mass panic. Besides these technical solutions, the government also showed strength in communication with the public, a soft skill that ultimately fostered trust in the authorities—a very important component in following any measures that circumvent personal freedoms.
It may be impossible to create a perfect epidemic response system unless a country is completely sealed off, but Taiwan has come very close. Unfortunately, the country’s pandemic response is not easily replicated—it is based on the past experiences, lessons learned, and institutional capacity created after sars. This paper has looked closer at the government’s (early) response to both these crises and found that one heavily influenced the other. In other words, thanks to the mismanagement of sars in 2003, by 2019—when the first news of an unknown infectious disease surfaced—the government was prepared to react quickly. That in combination with effective communication with the public strengthened trust in the ruling elite, based on which people exhibited more compliant behaviour towards the measures, with effective measures and high compliance the main ingredients for success.
Acknowledgements
This work was supported by the European Regional Development Fund—Project ‘Sinophone Borderlands: Interaction at the Edges’, cz.02.1.01/0.0/0.0/16_019/0000791.
Notes on Contributors
Alzbeta Loduhova earned her master’s degree in Chinese philology at the Palacky University Olomouc (Czechia). Besides Chinese, she has also studied the basics of some other languages including Japanese, Korean, Vietnamese, Indonesian, and Polish. During her master’s studies, she completed an internship in the Sinophone Borderland project (http://www.sinofon.cz/) in which she mostly focused on the covid-19 pandemic related to China, Taiwan, and European countries.
Kristina Kironska is a socially engaged interdisciplinary academic with experience in Taiwan affairs, relations between China and Central and Eastern Europe, Myanmar studies, human rights, election observation, and advocacy. After her PhD, she worked for a few years at Amnesty International. In 2019 she lectured at the University of Taipei and organised monthly human rights talks. Currently she is conducting research within the Sinophone Borderlands project administered by the Palacky University Olomouc (Czechia). She is also the advocacy director at the Central European Institute of Asian Studies, an independent think tank with branches in Slovakia, Czechia, and Austria.
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Taiwan never relied on mass testing and there was no urgency to secure a vaccine programme. Instead, the country relied on controlling the borders and keeping imported infections out of the country. The virus, however, managed to get through a small gap in the protocols (airline staff subject to loosened quarantine conditions).
The article was originally written in February 2021 and updated in summer 2021.
The charts, graphs, and photographs in all figures have been created by the authors.
Personal experience of one of the authors (September 2020).
