Written by Tsung-Mei Cheng.
Image credit: 07.13 總統出席「醫師公會全聯會因應疫情應變線上會議」by 總統府/Flickr, license CC BY 2.0
For much of the past eighteen months, the world has been under siege from the Covid-19 pandemic. Since January 2020, when the novel virus was first reported, the scourge has claimed more than four million lives and 189 million confirmed cases around the globe. In the Covid-19 saga spanning continents, damaging economies, and taking lives, Taiwan stood out as a poster child of success in preventing large outbreaks and keeping its economy growing at the same time. Taiwan today still has the fewest number of confirmed cases among comparable nations, and the second-lowest deaths per 100,000 population, after Singapore, as Figure 1 shows. The government’s policy of “control and prevention by keeping the virus out” had worked for a straight sixteen of the past eighteen months. Taiwan’s Centres for Disease Control data showed that as of April 13, 2021, Taiwan had a total of 1,057 cumulative confirmed cases and 11 deaths since January 2020.
However, within a few weeks, Taiwan encountered a sudden and first sharp rise in cases and deaths. The nine-week period May 11-through July 13 saw 14,103 new confirmed cases, which accounted for a whopping 92% of the total number of cases since January 2020. Likewise, deaths saw an equally dramatic increase, rising from 11 as of April 13 to 759 as of July 15, which accounted for 99% of all deaths to date. Figure 2 shows the surge in terms of the number of cases in 5-day intervals in the period.
The latest data out of Taiwan suggests that the outbreak is under control for the time being as new cases fell over time, as Figure 2 shows. The daily counts for July 15 were 18 confirmed cases and six deaths. These numbers are extremely low compared to comparable countries that are also experiencing surges in Covid cases and deaths, primarily due to the rapid spread of the highly contagious Delta variant of the coronavirus.
That Taiwan has been able to bring the outbreak quickly under control is testament to the effectiveness of the government’s interventions, which are based on an excellent Covid-19 prevention and control policy and infrastructure, which in turn was based on the myriad lessons Taiwan learned from the 2003 SARS crisis. Since the outbreak in mid-May, the government has stepped up measures such as testing, which it did not do previously because of the extremely low cases and deaths. The government has also been making extra efforts in contact tracing to identify all sources of contagion to eliminate the spread. For example, the mayor of Taipei, Ko Wen-Je, a physician, announced that although the number of cases identified has been decreasing in Taipei, there are still hidden “black numbers” – cases yet unidentified – within various districts in the city, the epicentre of the outbreak in Taiwan. To “exterminate” the sources of the spread, Mayor Ko went about finding each potential case by doing extensive testing despite the high marginal cost of the measure. According to Mayor Ko, 1,286 PCR tests were performed by seven hospitals in Taipei on July 13, which yielded two positive cases.
The sudden outbreak in mid-May after the stellar performance in the previous sixteen months of extremely low numbers of cases and deaths begs the question: what went wrong? One might reasonably think that the Delta variant sweeping across the world may be the culprit. That, however, appears not to be the case. Instead, the Alpha strain has been the overwhelmingly predominant strain in Taiwan’s outbreak, with “very rare cases of Delta in a small area” – based on author’s personal communication with the president and CEO of a leading cancer centre in Taiwan (July 15, 2021).
Among the oft-heard explanations for the outbreak are complacency, lack of preparedness, inadequate testing, vaccine supply, and vaccine hesitancy. Taiwan’s enduring success had led to its continued reliance on the tried-and-true regime of quarantine, contact tracing, and border controls to keep Taiwan safe until vaccines arrive, which policymakers count on to provide the ultimate protection of the population. Alas, the outbreak preceded vaccine arrivals. An article on June 4, 2021, Financial Times pointed to the lack of preparedness for the outbreak: Taiwan “was not prepared for a surge of infection … Infectious diseases experts say health authorities have squandered the chance to learn from the experiences that other countries had while going through outbreaks.”
The Financial Times article continued: “Taiwan needs to switch gears to fight first major Covid outbreak.” One area of preparedness is testing. Because Taiwan did not do mass testing before the outbreak, they did not have a chance to test the system and straighten out the kinks. When the surge hit, they found out that the procedural complexities surrounding PCR testing, the government’s favoured test, were cumbersome, leading to delays and several other testing-related problems.
Vaccine supply is a more complicated issue. There were delays and cancellations of contracts by vaccine manufacturers. It is unknown to what extent this may result from hard price negotiations between Taiwan and the multinational vaccine suppliers. A recent article in the New York Times suggested that this may have been the case with Canada, a fellow single-payer system like Taiwan: “Canadians have bargained hard with the pharma multinationals to get essential medications at reasonable prices. And now… this is their payback.”
There was also alleged interference by China to disrupt the delivery of contracted vaccine doses. According to German parliamentarian Ulrich Lechte, Chinese pressures caused the German vaccine manufacturer BioNTech to cancel an agreement that it had entered into earlier with Taiwan.
Finally, Taiwan’s policymakers and the public had hoped that domestically produced vaccines would become available by mid-July 2021 so that Taiwan could rely on its own supply of vaccines. To date, however, Taiwan’s own vaccine development is still at its final clinical trial stage. Former Vice President and health minister Chen Chien-jen, an epidemiologist, had volunteered to be a human trial subject and received what turned out to be a placebo of a Taiwanese vaccine in April. Former health minister Chih-Liang Yaung also receive a jab of a Taiwanese vaccine as a trial volunteer. Yaung believes that the government should have invested more heavily in domestic vaccine development.
In the meantime, Taiwan began receiving, in April, doses of the AstraZeneca vaccine. Since then, it has received additional vaccine doses from COVAX, the United States, and Japan. More are expected to arrive in the coming weeks and months. To date, 18% of Taiwan’s 23.8 million population have received one dose of an imported vaccine.
Vaccine hesitancy is another potential problem Taiwan faces. As of July 15, just 7.32 million Taiwanese, or 31% of the population, have signed up to be vaccinated. Many Taiwanese are sceptical of the efficacy of the AstraZeneca vaccine, the main vaccine on hand at present. Before the outbreak, many Taiwanese also did not regard getting vaccinated as urgent since Covid-19 was perceived to be well controlled. The outbreak and the arrival of different vaccines, such as the Moderna and Pfizer vaccines, may change some minds.
The outbreak in Taiwan has provided valuable lessons for Taiwan’s policymakers going forward. First, it has uncovered specific weaknesses in Taiwan’s health care system — an overall high performing health care system — as seen in the high Covid-19 case fatality rate. This should be of concern to Taiwan’s policymakers. Figure 3 shows that Taiwan’s case fatality rate of 4.90% is the highest among comparable countries whose rates range between 0.10% for Singapore and 3.00% for Italy, with the majority of comparable countries clustered around 1.00%-2.50%. Taiwan’s rate of 4.90% is also higher than those in Bolivia and Bosnia and Herzegovina – countries whose per capita GDP (in PPP) are far lower than Taiwan: Bolivia $8,832; Bosnia and Herzegovina $15,935; Taiwan $59,398.
A Taiwanese pulmonary specialist, who provides front-line care for Covid patients, shared on his Facebook that case fatality rates in Taiwan are greater than 5%; and those in Taipei city and New Taipei City, which are “Covid hot spots,” are 6.05% and 5.55%, higher than the global average. He attributes these high rates to an inadequate delivery system capacity for catastrophic diseases in Taiwan. That the case fatality rates are as high as these in the two largest cities in Taiwan, home to many of Taiwan’s best health care facilities, is concerning.
In an earlier article, I wrote on Taiwan’s response to the Covid-19 challenge. I pointed out that Taiwan may not be prepared for a sustained community transmission as “Taiwan faces potential shortages of both beds and personnel depending on the speed and scale of a community spread…” It appears that Taiwan’s otherwise high performing health care system was overwhelmed for a time by the sudden and unexpected outbreak in mid-May.
The mid-May outbreak may have opened a window of opportunity for Taiwan’s policymakers to make improvements to Taiwan’s health care delivery system — more specially equipped hospital beds, more staffing, more health care operations research for greater efficiency gains, etc. — to meet challenges from future public health emergencies. If making improvements to the health care system means higher spending for health care (Taiwan spends just a little over 6% of its GDP on health care), it would be a worthwhile investment in health for the people of Taiwan.
Tsung-Mei Cheng is a Health Policy Research Analyst at the Princeton School of Public and International Affairs, Princeton University.
This article was published as part of a special issue on Taiwan’s Covid-19 Spike.