In this series of papers, I want to explore why some countries were successful in combatting the pandemic and others, including Canada, were not. Why were some countries clearly more successful than others? Behind that question lurks another, more connected with prophecy than with retrospective analysis even though historians are very wary of engaging in predictions. How will the world change after Covid-19?
There is a family context to this inquiry. My oldest son, Jeremy, is a history professor at Princeton and a leading scholar on globalization. My two youngest sons, Daniel and Gabriel, were totally alert to the immanence of the pandemic in February when the West was just beginning to awaken to the threat. Recall that WHO did not declare a pandemic until March. In early February, my youngest sons insisted we not travel to Spain when there were only two Covid-19 cases reported in the country. They insisted in stocking us up with enormous amount of supplies when a week after we cancelled Spain I suffered a heart arrest. Behind the sensitivity of my youngest children to the enormous threat of the pandemic was a fine-tuned sensitivity to a tragedy that would make Covid-19 into a sideshow – the emerging climate change crisis. With this preoccupation came a concern with shifting attention from the global to the local.
I begin this inquiry with what has been the most apparent success story, that of Taiwan. Taiwan, a country of 23.6 million, is only 81 miles from Mainland China. It receives 2.7 million visitors a year from China and 1.25 million of its citizens work or reside in China. It is relatively densely populated, 651 inhabitants per square kilometer. One might have expected the country to have a very high rate of infection. In fact, it probably has the best record on earth. As of 5 May 2020, it has had only five deaths. Compare that to Canada with only a 50% greater population but over 4,000 deaths. The number of cases in Taiwan reached a peak of 307 on 6 April 2020. Taiwan now has only 427 active cases. The majority of those cases have been imported.
Some answers are readily apparent. First, Taiwan has had an excellent centralized system of disease control since the SARS outbreak in 2004. Data is collected and integrated using not only national health care statistics but migration and customs figures. Further, policy has a command centre – the national Health Command Center (NHCC) of the Taiwan Center for Disease Control (TCDC), the agency of the Ministry of Health and Welfare of the Republic of China (Taiwan). It is charged with combatting the threat of communicable diseases and had an excellent practice run with the 2009 swine flu pandemic. Further, it is not just an information collection and analysis agency nor one that simply proposes alternative policies; it has the authority to coordinate country-wide efforts to combat threats of communicable diseases and can enlist personnel and whole departments to its efforts.
Centralizing information, policy and decision-making is just the first key peg in the tale of success. This capacity was accompanied by swift action. On 31 December 2019, TCDC initiated inspection of inbound flights from Wuhan, China. Recall that it was a week later that Chinese officials reported a pneumonia outbreak that was not SARS. TCDC had quickly determined that the new disease was neither SARS nor Middle East Respiratory Syndrome (MERS), bird flu or an adenovirus when only 59 people from Wuhan had presented themselves with what appeared to be a unique disease characterized by fever, body aches, shortness of breath and signs of lung injury. Further, between 31 December and 6 January, Hong Kong reported 21 similar cases.
But TCDC was already off and running to collect information and determine the health challenge they were facing. This was at a time when Chinese authorities had censored the hashtag site, #WuhanSARS and “disappeared” some Chinese doctors who were issuing warnings of the new outbreak while other medical authorities in Singapore were urging calm and warning against a panic – such as Wang Linfa an expert in infectious diseases at the Duke-NUS Medical School. But the issue was not panic but preparation with information, policies and the implementation of immediate action.
By 5 January 2020, all flights from Wuhan were being monitored. Any individuals with any indication of the symptoms were immediately quarantined. On 21 January, Taiwanese health authorities had identified its first case, a 50-year-old teacher from Wuhan. On 28 January, a domestic case was identified. By 16 February, the first person had died. Almost a month later, there were almost 50 cases, one an American expatriate.
During this period, Taiwanese authorities took steps to ensure the country that the required PPE equipment (personnel protective equipment), including respiratory protective devices in stock in sufficient quantities. PPE equipment included facemasks, gloves, isolation gowns, eye protection, N95, powered air purifying and elastomeric respirators and ventilators. While during April, American political and medical authorities were panicked over the severe shortages, almost three months earlier, on 24 January, the Taiwanese government announced a temporary ban on the export of face masks. By early February, TCDC ordered the mobilization of the Taiwanese Armed Forces to work in factories to enhance 62 production lines for producing masks. By early March, just when Americans were beginning to become aware of their mask shortages, Taiwan was producing 9.2 million masks per day and by the end of March, production had reached 13 million.
Gowns were another story. Taiwan had relied on the American firm, Dupont, to manufacture and supply its safety gowns. On 16 March, as information gathered on impending American shortages even before Americans were aware of it, Tsai Ing-wen announced that Makalot and other Taiwanese industrial companies would begin the mass production of protective gowns. Respirators and ventilators followed a similar trajectory of a shift to domestic production and reliance even before other countries in the West were even aware of an impending severe shortage. Americans, in contrast, were advising on strategies to extend and re-use existing PPE supplies as contingency strategies, neglecting protocols rejecting re-use and stressing training on donning and doffing procedures. Hospitals were being advised to reserve PPE and replace PPE normally used for source control with other less effective barrier precautions. Thus, on 23 May 2020 – yes May – as Covid-19 patients turned up at Montefiore Medical Center in the Bronx, nurses were issues two – yes two – N95 masks for use for the whole week.
In Canada and America, people on the street are advised to but not required to wear masks. On 31 March, Lin Chia-lung required that anyone using transit had to wear masks and by 3 April were threatened with fines of between 3,000 and 15,000 NT$. At the same time, in early April Taiwan President Tsai Ing-wen donated ten million masks to countries suffering from the pandemic. At the same time, at the beginning of May, exports of hand sanitizers were banned.
The same preemptive story can be told about early screening, tracking and quarantining. By 17 April, 51,603 tests had been performed. Ontario reported that about the same time it had a capacity for 20,000 cases. Thus, extrapolating for the country as a whole, Canada with a population 50% higher could perform the same number of tests. It is generally agreed that widespread testing is a key tool for fighting coronavirus and the USA which had been totally derelict in this area in mid-March began to catch up to the rest of the world rapidly by mid-April.
Widespread testing is one of the most important tools for fighting the coronavirus, and while the US initially lagged behind many other hard-hit countries in its per-capita testing rate, it has been catching up. By mid-April, the USA was performing 150,000 tests per day. However, the US has just begun a program of contact tracing which has been central to the way Taiwan has tried to control the spread of the disease from the very beginning.
One major difference in Taiwan is that although it totally closed off travel abroad, there was no wide scale lockdown. Schools, though delayed in opening, schools and businesses were kept open during the pandemic.
Taiwan did not order its population to shelter in place. Taiwan’s economy did not suffer the shocks of Canada and the USA. Instead, its inspection and surveillance strategy were specific and targeted. Isolation and quarantine were strictly enforced. Masks became de rigeur. Most of all, Taiwan was totally open and transparent with its citizens, keeping them fully informed of each step and the rationale. Unfortunately, WHO ignored the warnings of Taiwan. Was Taiwan’s example followed by other Asian countries?