Written by Tsung-Mei Cheng
Image credit: 總統府, CC BY 2.0 https://creativecommons.org/licenses/by/2.0, via Wikimedia Commons
For more than two years since the global COVID-19 pandemic began in January 2020, Taiwan was remarkably successful in containing its spread and escaped the scourge of the deadly coronavirus. As of 9 April this year, Taiwan registered a low cumulative total of 26,836 cases and 854 deaths in the 27-months since the global pandemic. However, COVID-19 took its toll elsewhere in the world: more than half a billion people were infected, and 6.25 million died as of mid-May 2022. The United States alone saw more than 80 million cases, and on 16 May, the U.S. Covid death toll hit 1 million.
Taiwan’s smooth sailing from the very beginning through most of the spring of 2022 ran into strong headwinds when COVID-19’s highly transmissible Omicron variant took hold in Taiwan in April and quickly spread, as Figure 1 shows. As of 19 May, Taiwan’s cumulative total number of cases ballooned to 1,070,561 cases, a 40-fold increase since 9 April.
Going back several months to December 2021, Taiwan reported, on 23 December, a cumulative total number of 16,843 cases, including 50 points of Omicron — all “imported” by arriving overseas passengers, with 20 from the U.S.; and 850 deaths. This means that in the three-and-a-half-month period between late December 2021 and early April 2022, when Taiwan reported 26,836 cases, Taiwan’s cumulative total number of cases grew by just 10,000. Furthermore, figure 1 shows that in the period between January and early April, the daily case counts showed no peaks, suggesting that the situation was stable. Mercifully, just four deaths occurred in that period.
Speculations abound as to when the Covid surge might peak. In mid-May, the U.S. CDC placed Taiwan on its list of “high risk” nations.
That Taiwan was unable to circumvent a Covid-19 surge despite its earlier stellar record of keeping Covid-19 at bay through April this year begs the question: what went wrong? The Covid wave, driven by the Omicron variant, caught Taiwan by surprise. The government’s twin-pillar COVID-19 policy of “prevention and defence,” which emphasized preparedness, had worked so well for Taiwan for the entire time until Omicron showed up. So why did the policy not work this time? A key factor, it turned out, is the high transmissibility of the Omicron variant. This rendered the government’s earlier policy response to the Covid-19 crisis ineffective once Omicron arrived, according to Hong-jen Chang, M.D., former director-general of Taiwan’s National Health Insurance Administration and Taiwan-CDC. But there is another possible explanation judging from the roster of problems Taiwan faces right now: that Taiwan’s government was either unprepared or underprepared for the Covid surge or a little of both. The title of a 7 May article in one of Taiwan’s largest daily paper, United Daily News, citing an article on Taiwan’s Covid surge in UK’s Daily Mail is compelling: “UK Media Warns Taiwan Not Making Prior Preparations May Lead to Unprecedented Death Rates This Summer.” Many in Taiwan believe that the government lost valuable time not taking advantage of the window when things were going so well to prepare for contingencies such as an Omicron surge.
People in Taiwan feel the pain and anxiety the Omicron surge has caused. Problems unveiled by extensive media coverage include inadequate PCR testing capability and a shortage of home rapid-test kits, both of which created waiting lines. Also reported were delays in timely diagnosis and treatment because of inadequate PCR testing and shortages of home rapid- tests, overcrowded hospital ER departments, complex and confusing government rules and guidelines for testing, quarantine, and home isolation, delays in timely administration of drugs, such as Paxlovid, for patients with the confirmed diagnosis because of shortages, shortages of health care workers, etc. In addition, Taiwan’s health care delivery system is under threat of being overwhelmed as hospitals were ordered to, beginning 18 May, limited admission for inpatient care to only three categories of patients: medium-to-severely ill, febrile infants younger than three-month, patients deemed by their physician to need inpatient care for medically necessary treatments.
Deaths from COVID-19, however, remain low by international comparison despite the surge. Taiwan’s total number of deaths from Covid-19 per 100,000 population, at 5 deaths per 100,000, remains the lowest among comparable high-income OECD countries, as Table 1 shows. Table 1 also shows that the total absolute number of deaths from Covid in Taiwan is the second lowest among similar high-income OECD countries, after New Zealand. As of 19 May 2022, the total cumulative deaths from Covid in Taiwan was 1,235, and in New Zealand, 973. Taiwan’s population, however, is more than 4.6 times larger than New Zealand’s. Before the surge, Taiwan had the lowest number of deaths – 854 as of 9 April 2022.
Several factors explain Taiwan’s hitherto low Covid-19 mortality, despite the Covid surge. First, Taiwan’s government was prepared and had a well-planned Covid-19 prevention and defence strategy, which was put into action as soon as news about China’s Wuhan lab broke. Second, Taiwan’s National Health Insurance provided access to health care for everyone without financial barriers seen in many countries, including the U.S.
Third, Taiwan’s superb IT infrastructure makes real-time communication and coordination possible among government agencies such as the Ministry of Health, which oversees the entire anti-Covid-19 operation, Taiwan CDC, the National Health Insurance Administration, and the customs agency for border control. The IT infrastructure also allows the government to communicate with both the public and the private sector — such as hospitals, clinics, pharmacies, and convenience stores where the public can buy medical supplies such as facemasks and home Covid tests — to share important, real-time Covid-related information and monitor quarantine and contact tracing,
Fourth, the Taiwanese public’s ready willingness to cooperate with the government played and continues to play a key role in the fight against Covid-19. The public understands and accepts that everyone is in this fight together. People wear facemasks voluntarily, observe social distancing, and practice good hand hygiene. In addition, vaccine hesitancy is not a big issue in many countries, notably the U.S.
Finally, Taiwan has done well overall with vaccinating the population even though it started in earnest later than many other countries due to vaccine supply issues. As of mid-May, 86% of Taiwan’s population had had their first shot, 81% second shot, and 64% third shot or first booster. As a result, vaccinated people are less likely to get infected and develop severe diseases or die. Moreover, many vaccinated who get breakthrough Covid-19 infection have no or only mild symptoms. In Taiwan, 99.79% of cases today are either asymptomatic or have only mild symptoms. Figure 2 shows the population vaccination rates by age and number of shots received in Taiwan.
In early April, Taiwan’s government announced its decision to abandon the old “zero-COVID” policy favouring a new “Live with Covid” policy. The new policy aims to “focus medical and other resources on patients with severe symptoms, … those who are asymptomatic or with mild symptoms and close contacts should self-isolate at home.” The change represented a significant opening and loosening of previous restrictions. In an interview with CNN, Taiwan’s former vice president Chen Chien-jen, M.D., and a public health expert, explained the raison-d’être for the “New Model” of “Living with Covid” thus: “the ‘zero-Covid’ policy is too difficult and is tantamount to mission impossible,” acknowledging the high transmissibility of the Omicron variant. Several countries, in fact, had gone ahead of Taiwan and adopted the policy of living with Covid, some as early as September 2021: Denmark, Singapore, Thailand, South Africa, Chile; others followed in February this year: UK, Australia, New Zealand. Many more countries are considering doing the same.
Taiwan’s Covid surge is profoundly touching people’s lives today. Anxious, many ask if the government had a “Plan B” to deal with the unexpected (which the Omicron-led surge always was) that might have circumvented the tide. One wonders what kind of political fallout and how serious might one expect from the Covid wave. It is anybody’s guess. The simple answer is it depends on how well Taiwan’s government manages the surge-related problems people are experiencing and how quickly it can bring the surge to a halt. Learning to live with the virus is a work in progress in Taiwan. Nevertheless, the government has been making numerous changes to address the problems.
Time will tell how quickly Taiwan can bring the Covid surge under control. However, the fundamentals that worked so well for Taiwan before the surge—preparedness (a national plan), universal health coverage, advanced IT and communications infrastructure, and a cooperating public—should continue to serve Taiwan well in the fight against the current surge. Moreover, it will hopefully also defend us against future variants of the Covid-19 coronavirus to come.
Tsung-Mei Cheng is a Health Policy Research Analyst at the Princeton School of Public and International Affairs, Princeton University.