Taiwan’s ‘Iron Minister’: 2003 SARS Lessons Built Public Support For COVID-19 Response  
Taiwan Health Minister Shih-Chung Chen

If we could participate in the WHO and World Health Assembly (WHA), the warning messages we would give to the organisation would receive more weight, and this would probably result in better responsive actions.  – Taiwan Health Minister Shih-Chung Chen

Arguably, Taiwan has been repeating this statement  for decades. Yet when Chen’s mild words are matched with the COVID-19 pandemic experience, the familiar message is knife-sharp: WHO lagged for ten weeks after Taiwan started sending WHO warnings of a Chinese illness through its limited and informal channels on 31 December 2019. 

Weeks before WHO declared a pandemic on 11 March 2020, Taiwan had already implemented 124 pandemic policies other nations would have done well to emulate

Widely applauded for its management of the pandemic, Taiwan has one of the lowest per capita COVID-19 rates in the world and life on the island has largely returned to normal.

Taiwan’s plea to be included as an observer in the WHA and participate more actively in WHO expert consultations has become a broader topic of discussion this year  – perhaps due in part to the fact that with a population of almost 24 million, Taiwan suffered just 12 COVID-related deaths, with total reported cases only reaching 1,153 as of Tuesday. 

Even so, since 2016, after the Democratic Progressive Party won elections, Taiwan has been locked out of WHA participation, even as an observer – due to fierce objections from Beijing.  

The issue is sure to come up yet again at the upcoming World Health Assembly (24 May- 2 June), as one signal tweet by the US State Department spokesman last week, seemed to indicate. 

But the effectiveness goes beyond policy design and implementation. It reflects trusted leadership. When I returned to Taiwan in early February 2020, Minister Chen’s face was everywhere. 

From Dentistry to Pandemic  

Taiwan’s Health Minister didn’t start out as a rock star. Trained as a dentist at Taipei Medical University, Shih-Chung Chen (Chén Shízhōng) rose through the ranks of  Taiwan’s health leadership, becoming minister in 2017. He doesn’t mince words about China, but is known as the “iron minister” more for his sleep-in-the-office work ethic. Delivering hot meals to health care workers and other appearances also endeared him to the public.  

In our exclusive interview at Taiwan’s Central Epidemic Command Center, the minister who guided Taiwan through the pandemic explains how the 2003 experience with Severe Acute Respiratory Syndrome (SARS) led Taiwan to be prepared for the next threat.  

Health Policy Watch: Can you tell us the bare-bones story of Taiwan’s successful early interventions?  

Shih-Chung Chen: At the onset of the epidemic … no one really knew what was going on in China. But since we always have lots of interactions with China, we were quite attuned to relevant information, and were very alarmed when we received news [of a virus] from various sources. [Editor’s note: More than 800,000 Taiwanese live in mainland China, which is Taiwan’s primary business and export-import partner; cheap mainland labour also fills many low-end retail jobs in Taiwan.] 

We kept pursuing this topic and decided to act early on it. On 31 December 2019 we started with flight boarding inspections in the hope of stopping the virus from spreading, in case it did pose an epidemic threat. 

As a direct result from our SARS experience, the Infectious Disease Prevention and Control Act was already in place. This provided for horizontal communication between agencies during pandemics, as we knew very well that inter-agency cooperation is essential. [Based on the act], the Central Epidemic Command Center (CECC) was established on 20 January 2020. 

Three days later, when Wuhan locked down, the situation quickly escalated to alert level 2 – this mandated the multi-agency communication. On  25 February the COVID-19 Special Act was passed, and on 27 February  the CECC was established for the highest level of alert, under which all departments were required to send representatives to CECC for cooperative action. 

We collaborated closely with the Interior Ministry, since immigration, police and civil affairs are all under its jurisdiction. Because of this, we appointed the Interior Ministry’s Deputy Minister as our CECC ’s second in command.  

HP-Watch:  Can you comment on public adherence to pandemic guidelines?

S-C Chen: Every compliance requirement is hard to implement, although the actual rules themselves are not difficult. It’s easy to wear a mask and get new habits that discourage virus transmission – but to make all civilians willing to comply with these changes is hard.

Since in the longer term we want to be a trusted organisation, we decided to be transparent and start this conversation with the public using press releases and interactions through Internet platforms.  

Because the public perceives that we are transparent with policy, they have placed their trust in us and have complied well. It is because the public carried out these simple prevention practices that our first-line prevention efforts have been successful.

HP-Watch: Which Taiwan health policies do you consider most innovative? 

S-C Chen: First and foremost is our National Health Insurance (NHI), because this single-payer system is running well and has been effective in administering quality medical services with total coverage at low costs.  

The other experience we could share is how we succeeded in [pandemic] prevention while placing minimal restrictions on civilian life as a democratic country. These two aspects are what we could share most with the world, especially prevention.

Certain countries with more centralized authority were able to contain the pandemic with human rights tradeoffs. This is a contrast to Taiwan’s success as a democracy, and could be a good subject for study in the future.

Solid Privacy in Real-Time Cloud  

HP-Watch:Your high-tech, cloud-based information systems are widely praised, but outsiders often claim: they face commercial, privacy and legal issues in litigious private health systems. Have there been data breaches or other privacy nightmares with your system? 

S-C Chen: I don’t think there are data privacy controversies relating to the NHI system. . When the government centralized information on citizens, it is natural to worry that data will be used inappropriately. We should not avoid using cloud-based systems because of such concerns; instead we need laws that regulate how data can be used. 

It is two sides of the same coin  – you can only act fast when you have good information – and only have good information when data is timely. Whether the data is used for health administration or contributes to research advances and safer drug prescriptions … if you don’t get organised in those areas, then you won’t be enabled when you need them. 

Leaking of any data belongs to the realm of the law. So the law should be amended to regulate this area instead of [providing opt-out alternatives and] impairing the information system due to concerns over privacy. 

HP-Watch: What challenges do you see coming next, both in terms of COVID-19 and after Taiwan is immunised?

S-C Chen: Containment of the virus is going well currently. The next phase is vaccination. We have seen this offer encouraging results in countries like the US, Israel and UK. But we are also seeing failed attempts like Turkey and Chile, where after vaccination the pandemic got even more difficult to contain.Similar situations faced advanced countries such as Italy, Germany and Spain, with huge costs and losses. 

In relation to vaccination-related policies, civilians’ knowledge about the vaccines will be critical in determining vaccination’s ultimate ability to contain the pandemic. We will watch closely as other nations employ different vaccines and policies. There are new virus strains evolving and corresponding public worries whether vaccines will be effective; these doubts have influenced some people’s willingness to be vaccinated. 

I think we should be humble when we face the virus, but not be fearful without any limit. We should face the problem proactively, solving these issues one by one and collaborating with the world. 
Equal Isn’t Fair in Health Budget Cuts 

Another issue we are facing is the reform of NHI policy. We have a strong centralized power and fiscal policy: we have a total budget to execute and this budget dictates what we can spend. 

Our national insurance policy is run by the government based on a single-payer system. This means that adequate planning is critical… Too much centralized control created many issues, so alternatives in setting budget priorities should be discussed.  

It is not working to cut spending solely based on total budget changes. In other words, improving the health care system rather than solely suppressing medical expenses for better-looking numbers is one issue that we have to face.

 As far as the budget goes, the public wants to see how their health can benefit if more money is allocated to NHI, so we have to see how the budget can best serve people’s well-being. Since we have total coverage, everyone will share in these changes. 

Message to the World 

HP-Watch: Is there anything you wish the world understood about Taiwan’s health system and its anti-pandemic policies? Clearly both are unusually effective, yet Taiwan is often misrepresented through China’s claims when it receives global coverage at all. 

S-C Chen: For a very long time, China has used its political power and UN memberships as a roadblock to Taiwan in terms of public relations. But I think now, due to COVID-19, more countries are recognising China’s closed system and errors as well as the subsequent [health] effects from those errors.  

When global powers around the world see China’s actions and errors, this shifts the political atmosphere. Taiwan is eager to play a positive role, and especially now we should be proactive in service and exchanges. We want to be recognised globally for our policies, but also recognised for our engagement with global health and our long record of service. 

Internationally, Taiwan continues to seek ways to participate in the global health system. We also participate by providing our experience and supplying physical aid, and we will continue to help countries with health-related needs. 

However, due to our diplomatic situation and certain countries that don’t want Taiwan to serve in international organizations … we do experience setbacks. In the future, we hope like-minded countries will come to our side. This diplomatic help will allow Taiwan to help in more health-related contexts.

In the grander scale of things, future pandemics certainly can be even worse..Human disrespect for nature can bring disaster, destroy habitats and so on. 

It all comes down to what we understand: there are people who tend to think human beings are more powerful than nature. With this pandemic experience we will be more humble — knowing our limits and realising we can’t fight nature, but must co-exist with it. 

  • Val Crawford has worked in international news and scholarly publishing, and edited for United Nations University in Tokyo and the World Health Organization. She taught scientific writing, journalism and popular culture courses at Taipei Medical University from 2010 to 2019, and served as visiting professor at the University of the Philippines and Sri Ramachandra University in Chennai, India. 


Image Credits: Wikipedia.

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