tsung-mei cheng is health policy research analyst at Princeton University’s School of Public and International Affairs. This article was adapted from her analysis in Economics Observatory, a non-profit public policy website in the UK.
Published January 12, 2022
Taiwan has fared far better than most countries during the Covid-19 crisis — and for a whole host of reasons, the most important of which is probably a sense that individuals have a responsibility to help protect the community. To date, Taiwan has gone through two phases of its Covid-19 crisis with somewhat different outcomes for each, and it is currently in the middle of a third.
Phase I: January 2020 to mid-May 2021
Taiwan’s escape from heavy casualties in this period was the result of measures taken early on. At the end of December 2019, when public health officials in Taiwan learned of an outbreak of infections caused by a then-unknown pathogen in Wuhan, China, the government wasted little time preparing for the disease’s arrival. It activated a national strategic response plan prepared in the years after China’s 2003-4 SARS crisis. The immediate response (January 1, 2020) was to impose stringent cross-Taiwan Strait travel restrictions. Essentially, Taiwan closed its borders to flights between the island and China, except for flights from four designated Chinese cities to allow Taiwanese citizens living in China to return.
By mid-January 2020, Taiwan had established the Central Epidemic Command Center (CECC) to lead on all Covid-19 related matters. Headed by Health Minister Chen Shih-chung, it works closely with Taiwan’s Centers for Disease Control, the National Health Insurance Administration (which runs Taiwan’s single- payer health insurance system), the immigration authority and the private sector. Recognizing the crucial importance of transparency, the CECC held daily news conferences. These reported on cases and deaths, new developments and any measures introduced to control Covid-19. Measures included strict travel advisories and entry protocols tiered by the estimated risk levels of specific countries, 14-day home quarantine protocols according to individuals’ risk levels, contact tracing, mask wearing, social distancing and hand hygiene.
Contact tracing and quarantine in Taiwan have been highly effective in preventing large-scale community spread, thanks to the country’s advanced information and communications technology infrastructure. Taiwan’s interoperable ICT platform enables various government agencies access to real-time big data. The system also facilitates close real-time interactions between government agencies and private sector actors, such as pharmacies, convenience stores and the predominantly private healthcare delivery system
The public has cooperated closely in contact tracing and quarantine — which differs from the country’s experience during the SARS crisis, when people did not trust the government and often hid from authorities. This cooperation made it possible to prevent the spread of Covid-19 without resorting to costly measures used elsewhere, such as large-scale testing and closing schools and businesses.
But one indirect consequence of this success was a slow response to vaccine innovation. A combination of extremely limited access to vaccines and popular vaccine hesitancy resulted in little uptake. As of mid-April 2021, just 27,000 Taiwanese (an insignificant portion of the population) had received one dose of the only vaccine available to them at that time (AstraZeneca).
Phase II: Mid-May 2021 to July 2021
True to the Chinese saying that “all feasts under the heavens come to an end,” in mid-May 2021 the number of Covid-19 cases in Taiwan suddenly jumped. On May 11, the Minister of Health and Welfare declared Taiwan had officially entered the phase of community spread that policymakers had feared and moved the Covid-19 emergency alert from level 1, the lowest of four levels, to level 2.
As of May 22, 2021, the CECC reported a cumulative total of 3,862 cases and 17 deaths. The Financial Times concluded that the authorities had “squandered the chance to learn from the experiences that other countries had while going through outbreaks.” As mentioned earlier, vaccination rates at this time were extremely low, and testing capacity was limited. In addition, there was a shortage of special intensive care beds and medical personnel.
The vast majority of these cases were concentrated in the two major population centers in Taiwan’s north: Taipei City and New Taipei City. This turned out to be, perhaps, the saving grace, for it gave the government time to implement a rapid response by declaring a level-3 emergency alert for the two cities.
To be on the safe side, the level-3 alert was subsequently extended to all of Taiwan on May 19. Emergency measures included a mask mandate; banning large gatherings; and closing cinemas, indoor restaurants, swimming pools, public libraries, elementary and middle schools, and day-care centers for both children and the elderly. Indoor social gatherings were limited to five people and outdoor gatherings to ten.
Border controls remained in effect, with the number of flights allowed to land in Taiwan pegged to the country’s healthcare capacity at the time to avoid overwhelming the system. Still, demand for hospital beds exceeded available spaces, and there were reports of long waits for beds and of Covid-19 patients being treated outdoors on hospital grounds.
But the situation, tense as it was at the height of the outbreak, came under control within weeks. New cases came down dramatically by the end of June, and by mid-July, the Ministry of Health downgraded the emergency alert to level 2 and loosened contact restrictions.
Although short-lived, the outbreak did take a toll on Taiwan’s economy. Consumer spending in Taiwan declined by 4.2 percent in the second quarter of 2021. Services were hit hardest, with many businesses cutting workers’ hours to save costs. Unemployment reached an (albeit modest) ten-year high. But the bad news should be seen in perspective. Exports continued to enjoy growth (a sizzling 12.1 percent in the first quarter) thanks to re-opening and increased consumer spending in Europe and the United States. And projected GDP growth for 2021 remains a robust 5.9 percent.
The public regards cooperation with the government in national emergencies as a civic responsibility and shares the understanding that everyone is in this together.
Phase III: August 2021 to December 2021
Since September, new cases of domestic transmission have been at either zero or in the low single digits. Deaths have also remained very low: for nine days between September 29 and October 8, Taiwan reported none at all. This was at a time when the average daily deaths in the United States approached 1,900, with many days exceeding 2,000 fatalities.
Schools in Taiwan are open and other restrictions, such as the permitted size of gatherings and opening of sports and recreational facilities, are gradually being relaxed. Taiwan is also making good progress on vaccinations. As the year ended, two-thirds of the population had been fully vaccinated. One vaccine (Medigen, based on technology similar to Novavax’s vaccine) is being produced domestically.
As of late December, Taiwan had reported a cumulative total of 850 deaths from a bit fewer than 17,000 cases — about 700 cases per million population. These are extremely low numbers compared to all but a handful of countries. And in many cases the differences are mind-boggling: the United States had suffered about 840,000 deaths from 53 million cases in the same timeframe — about 160,000 cases per million!
What was different about Taiwan’s approach? In particular, what enabled the country to limit cases of Covid-19 in the first 16 months of the pandemic and then to control the outbreak quickly in May 2021?
First, Taiwan was prepared and acted at the first signs of the virus in early 2020. To that end, the government strengthened Taiwan’s CDC and healthcare delivery systems, and taught the public the importance of face masks and temperature checks early on. In addition, a 2011 constitutional ruling had granted the government power to do all that was necessary in public health emergencies, making mandatory quarantine possible during the crisis.
The CECC and Taiwan’s state-of-the-art ICT infrastructure have also played crucial roles. The CECC exercises central command and oversight for all measures concerning Covid-19 control and prevention. Advanced ICT infrastructure drives government and private sector Covid-19 related operations, including data collection, which helps the government with data-driven decision making. For example, the government knows in real time the potential exposure of all arriving passengers and has the technical capacity to enforce quarantine through effective tracking of people.
The NHIA IC-card, which every Taiwanese person carries to access medical care anywhere in the country, lets doctors and hospitals see the cardholder’s travel history (domestic and overseas), health records and quarantine status. The card also makes access to personal protective equipment such as face masks more equitable because it keeps track of when the cardholder last bought PPE supplies. This eliminates hoarding, which has happened frequently in many countries when cases spiked.
Taiwan’s ICT infrastructure, it’s worth noting, works to facilitate information flows in both directions. For example, using their mobile phones, residents can check the real-time availability of PPE at nearby pharmacies and convenience stores, and reserve pickup times. They can also monitor government notifications of new cases found and their precise locations in real time so they can avoid the hot spots.
Finally, the voluntary cooperation of Taiwan’s public has also played an important role. Like the government, the public learned important lessons from the 2003 SARS crisis, including basic public health practices like performing hand hygiene, wearing face masks and social distancing. More important, the experience from this earlier pandemic changed the public’s attitude from distrust in government to willingness to accept measures to prevent spread.
Difficulties frequently encountered in many Western countries with contact tracing, quarantine and face mask resistance have not generally been problems in Taiwan, and vaccine hesitancy is largely a thing of the past. The public regards cooperation with the government in national emergencies as a civic responsibility and shares the understanding that everyone is in this together. The importance of these two attributes cannot be overstated in driving Taiwan’s highly successful response to the pandemic.