Taiwan has been successful in suppressing the highly infectious Coronavirus Disease 19 (COVID-19) despite its proximity to Wuhan, China, where the coronavirus first emerged in December 2019. Taiwan recorded 517 coronavirus cases and 7 deaths in contrast to the similarly sized population of Australia, which confirmed 27,133 cases and 894 deaths as of 3 October 2020 (Johns Hopkins n.d.). Journalists across the world have attributed Taiwan’s success against COVID-19 to its experience fighting Severe Acute Respiratory Syndrome (SARS) in 2003 (Fortune 2020; CNN 2020). “The secret of Taiwan’s success,” a Turkish journalist argued, “lies in the painful memories of the 2003 outbreak” of SARS (Anadolu Agency 2020). Yet, these journalists have found it difficult to elaborate on Taiwan’s learning from its SARS experiences in the format of a newspaper article. Drawing on historian Virginia Berridge’s (2018) approach in writing a policy-orientated contemporary history of medicine, this article shows how Taiwan centralized antipandemic measures, resolved the lack of personal protective equipment (PPE), and challenged the World Health Organization (WHO) and China’s state medical advisories to fight COVID-19. Just as Taiwan adopted these same measures to redress SARS-era issues, Taiwan’s COVID-19 actions could serve as global health lessons for other countries fighting the current and future pandemics.

In contextualizing Taiwan’s success in fighting COVID-19 in its longer political history, this article problematizes the straightforward utilization of global health lessons from Taiwan. Policy makers should strive to understand how international and domestic politics interacted with Taiwanese medicine to fully understand the historical conditions underpinning Taiwan’s successful antipandemic measures. Significantly, the same ruling political party, the Democratic Progressive Party (DPP), fought SARS in 2003 and COVID-19 in 2020. When fighting SARS in 2003, the DPP government had to engage with the United Nations’ health agency WHO, which it was no longer a member of because Chinese Nationalist Party (Kuomintang, KMT)-led Taiwan lost its UN seat in 1971 to the People’s Republic of China (PRC). Attempts by Taiwan to join the WHO from the 1990s onward have been stymied by the PRC, even though the PRC permitted pro-Beijing KMT-led Taiwan to attend the World Health Assembly as an observer under the name “Chinese Taipei” from 2009 to 2016 (AFP 2020).

In 2003, the DPP government fought SARS as a longstanding opposition movement struggling to run the country after fifty-five years of largely authoritarian KMT rule. An inexperienced DPP central government (which won its first presidential election in 2000) had to work with a popular KMT mayor of Taipei City, Ma Ying-jeou. (Epoch Times 2003). This resulted in a contentious central-municipal relationship, similar to the contentious federal-state-local-media dynamics that have been playing out in the United States fight against COVID-19 (Washington Post 2020). This article will analyze three specific elements of Taiwan’s antipandemic measures to explore the tensions between the central Taiwanese and municipal governments: (1) antipandemic leadership; (2) DPP’s engagement with WHO on the diagnosis, prevention, and treatment of SARS; and (3) medical connections between China and Taiwan in shaping pandemic measures.

The latter two cases reveal the importance of international health diplomacy in shaping antipandemic measures. The article argues that the KMT’s role was crucial, if understated, in shaping global and cross-straits medical norms in Taiwan, even though the DPP government has traditionally been seen in a better light in resolving these pandemic issues. It also shows how the DPP engaged with WHO guidelines even as its efforts to join the organization have not succeeded. The brief cooperation between Taiwan and China in fighting COVID-19 in early January 2020, despite the official tensions between DPP and China, reveals the surprising endurance of the political connections built by KMT and China a decade ago.

1 Importance of Central-Municipal Interactions in Fighting Pandemics

Taiwan’s Central Epidemics Command Center, or CECC, has been lauded by the media as the key to the country’s success at fighting COVID-19 (South China Morning Post 2020; Deccan Chronicle 2020). Beginning from January 20, 2020, the Minister of Health and Welfare’s daily updates on Taiwan’s antipandemic measures has reassured the Taiwanese public. In a May 2020 poll, 94 percent of Taiwanese said they were satisfied with Minister Chen Shih-Chung’s performance (Peng 2020). Municipal authorities did not hold competing daily coronavirus briefings, in contrast to the United States, where many state governors held regular COVID-19 press conferences alongside the White House’s daily briefing, often providing competing information (Washington Post 2020). In Taiwan, municipal authorities (several led by non-DPP politicians) were involved mostly in the implementation of quarantine policies as well as taking charge of the process of reopening up sectors of the economy closed by the central government to fight COVID-19. As the COVID-19 crisis abated, non-DPP politicians and pro-KMT talk show hosts (mingzui 名嘴) argued that the central government should have taken responsibility for the reopening of hostess bars in Taiwan since the latter was the one to temporarily shut them down to prevent the spread of the coronavirus (United Daily News 2020; Shaokang 2020). While such criticism appeared to undermine the DPP, in reality, it revealed that non-DPP local forces recognized the DPP’s legitimacy in fighting COVID-19 to the extent it sought to delegate power on reopening hostess bars to the central government.

The creation of the CECC in 2020 emerged from bureaucratic infighting in 2003 during the SARS period, during which the central and the municipal governments had failed to coordinate antipandemic measures. A highly infectious coronavirus with a high mortality rate, SARS first emerged in the Guangdong province of China in February 2003. The virus reached the shores of Taiwan in March 2003 (Washington Post 2003). In April 2003, Taiwan experienced a severe outbreak of SARS at the Hoping Municipal Hospital in downtown Taipei.1 Initial reports of the outbreak precipitated a meeting between representatives of the DPP central government and the KMT Taipei municipal government. Led by mayor Ma Ying-jeou, the Taipei government persuaded the central government to immediately quarantine medical personnel and patients in the hospital to prevent a community outbreak of SARS. They also recalled off-duty medical staff to the hospital for mandatory quarantine.

The Taipei municipal government delegated most of its antipandemic measures to the Hoping Municipal hospital leadership. Without explicit instructions on how to prevent additional outbreaks within the hospital, the hospital leadership failed to protect its doctors and nurses from new infections. The city’s government did not provide adequate PPE, such as surgical masks and face shields, for hospital personnel. Doctors and nurses feared for their lives. Several of them sought to escape from the hospital and could even be seen climbing out of hospital windows. They staged demonstrations outside the hospital, demanding more PPE as well as a clear and convincing intervention that would improve testing, tracing, and isolation policies to prevent additional infections of SARS. Cases exploded within the hospital. One patient jumped to his death out of despair. The term “hospital transmission” (yuan nei gan ran 院內感染) became a notorious term in Taiwan. WHO’s refusal to send medical experts to Taiwan as well as reluctance to share information directly with Taiwan (as it considered Taiwan as a province of PRC) was only partly mitigated by United States CDC experts who rushed to Taiwan to assist hospital personnel (Chien 2003; Feng 2003). Eventually, more than 150 people were infected and 24 people killed by SARS in the hospital.

The DPP central government and the KMT municipal government blamed each other for causing this outbreak. The Minister of Health and Welfare in the DPP government argued, “We appear to believe too much in Taipei City’s government’s abilities” to resolve the crisis (Feng 2003). The Taipei City’s health bureau chief criticized the central government for not sending experts from the executive branch or Taiwan’s CDC quickly enough to assist hospital leaders in resolving the crisis (Su 2004: 159). She opposed the central government’s later decision to override the municipal government in redirecting Hoping Hospital patients to other hospitals, deeming this process of ending quarantine early as unscientific. She claimed that most international health experts would oppose such a decision.

The DPP government used WHO guidelines to criticize KMT officials. Chih-Wen Kao, a member of the CDC, traced the Hoping Hospital contestations to the beginning of the SARS crisis in March 2003, when the CDC opposed more extensive antipandemic measures proposed by the Taipei City government. Citing WHO recommendations, the CDC advocated for a ten-day quarantine rule, a fever of 38 degrees Celsius (100.4 F) as a marker for SARS symptoms, and only optional mask-wearing among the general public (Su 2004: 141–42). The Taipei City health bureau disagreed, pushing for a more extensive fourteen-day quarantine, a fever of 37.5 degrees Celsius (99.5 F) for a SARS diagnosis, and active encouragement of mask-wearing among the public. While the central government saw the Taipei City government as causing unnecessary panic among the public with these measures, the municipal authorities blamed the central government for not correctly designating the disease as communicable early enough. The Taipei government’s stricter diagnosis and preventive measures towards SARS in March 2003 explain why the municipal government pushed for an immediate quarantine of the Hoping Municipal hospital a month later. In retrospect, KMT municipal authorities might have been correct to pursue more extensive intervention given the unpredictable nature of SARS. However, their poor handling specifically of the hospital crisis in Taipei undermined recognition of the benefits of the cautious municipal approach, casting it instead as unnecessary and ill-informed.

2 Learning Global and Domestic Lessons from SARS in Fighting COVID-19

Taiwan appeared to have fought COVID-19 well at the outset by rejecting WHO and China’s weak early advisories. First, Taiwan ignored the WHO and China’s insistence in early January that there was no evidence of sustained human-to-human transmission of the coronavirus. On December 31, 2019, the DPP government emailed WHO using the International Health Regulations (IHR) Focal Point mechanism on the same day China first informed WHO of unknown cases of atypical pneumonia in Wuhan (Financial Times 2020). WHO (2007) had established the IHR to redress the lack of international antipandemic coordination during the SARS crisis, and included Taiwan explicitly in the IHR mechanism in 2009 (Taiwan CDC 2009). However, the WHO did not reply to Taiwan’s request for more information, spurring Taiwan to dispatch two doctors instead to Wuhan on 13 January 2020 to better understand the virus. The doctors’ report convinced the DPP government that the coronavirus could transmit from one person to another (Telegraph 2020). Immediately on 15 January 2020, Taiwan began screening visitors from Wuhan for symptoms of coronavirus, even though as Figure 1 shows, the WHO (2020) maintained that there was no sustained human-to-human transmission of COVID-19 just a day earlier. On 20 January 2020, the DPP government established the CECC (Taiwan Centers for Disease Control 2020). At the same time, Taiwan deployed thermal scanning technology developed to fight SARS at airports to identify fevers among people entering Taiwan (NBC News 2020).

Second, Taiwan ignored the WHO’s recommendation that countries not ban visitors from China (ABC News 2020). Taiwan was the first nation to ban visitors from Hubei Province on 26 January 2020 (Reuters 2020a). On 5 February 2020, Taiwan banned all visitors from China, following a similar travel ban implemented by the United States three days earlier (Reuters 2020b).

Third, Taiwan rejected the WHO’s initial recommendation that ordinary people need not wear masks to protect themselves from COVID-19 (VOA News 2020).2 The DPP government began sixty production lines in mid-January 2020 to manufacture adequate surgical masks for the entire population of around 23 million people (Radio Free Asia 2020). Taiwan was quickly producing more than 13 million masks a week, which allowed all Taiwanese to purchase nine masks every fourteen days. The DPP adopted this policy in 2020 to remedy the KMT municipal government’s inability to provide enough PPE for healthcare workers during the SARS crisis. However, such a move also represents a remarkable cooption by the DPP administration of KMT’s calls for everyone to wear a surgical mask during the SARS crisis in 2003. With the widespread provision and wearing of masks and the development of a comprehensive and humane quarantine procedure for all Overseas Taiwanese returning to Taiwan (New York Times 2020), it is no wonder that Taiwan boasted one of the lowest rates of COVID-19 in the world.

3 Why Historical Connections between Taiwan, China, and WHO Matter

The DPP government’s success in fending off COVID-19 was underpinned by historical connections between Taiwan and China, Taiwan and the WHO, and the DPP and the KMT. The KMT, WHO, and China were not simply foils for DPP’s successes. Taiwan’s knowledge of the coronavirus first came from a member of its diaspora living in Wuhan, who posted Wuhan laboratory reports and doctors’ messages on unknown pneumonia on a Taiwanese internet messaging board known as the PTT Bulletin Board System (Watt 2020). This news caught the eyes of a medical administrator in Taiwan, prompting discussions among Taiwanese leaders on a possible epidemic in China. The whistleblower was one of the thousand or so Taiwanese expatriates living in Wuhan, reflecting the longstanding presence of Taiwanese businesspeople in China, which began after Chinese leader Deng Xiaoping opened up the country in 1979. This intervention by a member of the Taiwanese diaspora in China augments narratives of contemporary tensions between the Chinese and Taiwanese governments.

China’s support for the increasingly pro-Beijing KMT government from 2008 to 2016 ironically facilitated the DPP’s success in fighting COVID-19 in 2020. As part of a broader Economic Cooperation Framework Agreement (ECFA), China signed a medical treaty with the KMT-led Taiwan in December 2010, facilitating cross-straits medical exchanges as well as the sharing of relevant information on epidemics and diseases in their respective polities (China Daily 2010). This medical treaty provided the legal basis for Taiwan to request permission for two Taiwanese doctors to visit Wuhan as early as 13 January, 2020; a privilege denied to American visitors until more than a month later. As mentioned above, their visit convinced the doctors that there was indeed human-to-human transmission, which kickstarted DPP’s early interventions. Even though the ECFA agreement remains deeply unpopular in Taiwan and precipitated the major electoral defeat of the KMT in 2016, it ironically provided the basis for the early response of DPP’s administration to the pandemic (Washington Post 2016). Moreover, Beijing and Wuhan’s surprising adherence to the cross-straits medical treaty facilitated an early antipandemic intervention by Taipei.

Furthermore, the KMT government introduced an excellent universal health system in Taiwan in 1995 through a national health insurance (NHI) system, which has helped it to more successfully fight pandemics since. After losing power in 2000 and regaining it in 2008, the KMT raised monthly NHI premiums in May 2010 to reverse persistent financial deficit (TendersInfo 2010). In 2020, the DPP administration used the NHI card (which every enrolled Taiwanese brings with them when visiting the doctor) to distribute surgical masks to every Taiwanese (Radio Taiwan International 2020). Upon inserting the NHI card into a reader, pharmacists and clerks would know whether a person has purchased his or her quota of masks. Taiwanese authorities also synced immigration records for the last fourteen days with the NHI card to inform physicians if a patient had recently visited countries with COVID-19 cases. Some critics have questioned whether the government will adequately protect the use of such immigration and medical records (Ngerng 2020). In any case, DPP’s ability to marshal the NHI to fight COVID-19 owed much to the development of the NIH by the previous KMT administrations.

Finally, the DPP did not simply have a contentious relationship with the WHO. Recall a Taiwan CDC staffer specifically cited WHO guidelines in establishing the standard of diagnosis, prevention, and therapy for SARS in his dispute with Taipei municipal health authorities in 2003. In May 2020, Taiwan sought global support to become a member of the WHO (Fletcher 2020), even though the WHO director accused Taiwan of racialized attacks against him (Al Jazeera 2020).

4 Longer and Recent Histories in Global Health Lessons

Taiwan drew on its successes and challenges from fighting SARS in its fight against COVID-19 seventeen years later, suggesting several global health lessons for policy makers. The Taiwanese government drew solutions from the previous experiences of both parties. It corrected the lack of PPE during the SARS period, centralized antiepidemic measures to avoid municipal-level incompetence or critiques of lack of leadership, and maintained a healthy awareness of China’s infectious diseases.

The longer history of medicine and society in Taiwan influenced the country’s decisions in revising antipandemic measures. The Taiwanese highly valued medical education during the Japanese colonial period (Lo 2002). The post–1949 period saw United States-based officials and experts supporting the growth of medical education and establishing a universal healthcare system in Taiwan (Soon 2020; Palfreman 2008). The NHI system made the access to healthcare affordable during times of pandemic. While their positions on premium pricing and comfort with various levels of public health restrictions have not been unanimous, both the DPP and KMT have grown committed to delivering equitable economic growth and high quality of living through democratic means.

Global health experts, historian Randall Packard (2016) argues, have consistently overlooked improving the social determinants of health in favor of enacting immediate antipandemic measures in the countries they claim to work for. With the assistance of the United States, Taiwan has been successful in improving its social determinants of health and in enacting effective antipandemic measures. However, Taiwan is rarely included in the study of global health, even though it is an instructive example of how a non-western nation fought pandemics in a vibrant democracy based on an excellent healthcare system.

As Sigrid Schmalzer (2019) argues, the more recent history of terracing practices among peasants in the Maoist period were just as important as the longer histories of ecological knowledge in shaping agricultural development in China. In the case of Taiwan, the DPP government’s successes in fighting pandemics reflect the lessons it has drawn from previous clashes with, but also lessons learned from, the KMT, WHO, and China. The DPP took on the mantle of opposing the WHO’s insufficiently cautious recommendations from KMT for its antipandemic measures in 2020. Moreover, the DPP’s rejection of WHO and Beijing’s advisories on the lack of human-to-human transmission of the coronavirus in early January 2020 was premised on KMT’s signing of ECFA in 2010 as well as the DPP’s engagement with WHO norms in 2003, and desire to join the WHO in 2003 and 2020. Finally, Taiwan’s National Health Insurance-based universal healthcare system that began in 1995 under a KMT administration did not fully protect Taiwan from SARS outbreak in 2003, but had been bolstered enough by both parties in the interim so that in 2020 the DPP government could use NHI cards as a critical technology to distribute surgical masks among the entire population.

Policy makers and historians have much to learn from Taiwan’s efforts at centralizing antipandemic measures, providing surgical mask production for all citizens, and calibrating their engagement with international health organizations and foreign nations. These measures, however, were underpinned by unexpected continuities and historical slippages associated with Taiwan’s recent history. Understanding how medicine and society interacted with Taiwan’s democracy would help policy makers as to calibrate Taiwan’s lessons for their own fight against COVID-19.

Notes

1

My analysis of the Hoping Hospital outbreak draws from Sylvia Feng’s 2003 documentary for Taiwan’s Public Television Station as well as Yun Fan and Ming-chi Chen’s (2014) arguments.

2

The WHO did not reverse its position on wearing masks until 5 June 2020 (Guardian 2020).

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