Containing coronavirus: the lessons from Asia
The effective response in Taiwan and South Korea has been shaped by traumatic memories of Sars
When Su Ih-jen looks at the latest coronavirus statistics, he cannot help but feel proud. With just 59 confirmed cases and one death as of Sunday, Taiwan has managed to avoid a major outbreak of a disease which has paralysed neighbouring China. Apart from most people wearing masks on public transport, life goes on as usual. The experience is a stark contrast to 2003, when Prof Su, then the director of Taiwan’s Centers for Disease Control, was at the forefront of the battle to contain severe acute respiratory syndrome, which had a devastating impact on the country.
The mood in Taiwan also drastically differs from the sense of panic and confusion in Europe and the US, where the arrival of the pandemic at their doorstep has come as such a surprise to many. “The situation in other countries now resembles the situation we were in during the first few weeks of the Sars spread in Taiwan in early 2003,” says Prof Su. “You are not ready, you have no experience.” The good news for the western governments now scrambling to respond is that the measures Taiwan and other Asian countries have implemented over the past three months have been shown to slow and even blunt the impact of disease. After the SARS epidemic, Professor Su Ih-jen overhauled Taiwan's entire public health system © Andy Wong/AP Early travel restrictions, aggressive testing and screening of contacts and strict quarantine rules have been key.
Universal healthcare, clear management structures for the public health response and proactive communication to get the population on board have also helped. These policies have managed to contain the virus in Taiwan and Singapore and reduce or slow infection rates in South Korea, Hong Kong and Japan.
While the World Health Organization has suggested other countries learn from China, which it has praised for “perhaps the most ambitious, agile and aggressive disease containment effort in history”, some health experts believe that Asia’s democracies, such as Taiwan and South Korea, may be better models for epidemic management in western countries, given the different nature of the Chinese political system. “One of the most important factors in the success of our response has been transparency,” says Chang Shan-chwen, a leading expert on infectious diseases and convener of the expert advisory panel to the Central Epidemic Command Center, which manages Taipei’s response.
“In [China’s] autocratic system, every citizen will stay at home when told so. But this is something which cannot be easily achieved in free and democratic countries.” The bad news for western governments, however, is that one vital component of the Asian response cannot be replicated. The region’s approach has been shaped by the traumatic memories of other recent epidemics — most notably Sars — which meant that governments were better prepared to react fast and forcefully and populations much more willing to co-operate. Leighanne Yuh, an expert in Korean history and culture at Korea University, says the experience from Sars and other recent epidemics, as well as watching the rapidity of the coronavirus’s spread through China, has instilled a “sense of urgency” and adherence to “social courtesies” across the country. “Because South Korea has had these types of outbreaks already occur, they know the kind of steps that need to be taken and how serious the danger is,” she says. “If we compare it to the United States, which hasn’t really been exposed to these things, at least for a long time, their response has been quite different.” For South Korea, the Asian country that suffered the biggest outbreak apart from China, testing as many people as possible has been a key pillar in its strategy for combating coronavirus.
At “drive-through” testing facilities, officials clad in white hazmat suits can be seen leaning into cars to take fluid samples from the driver and passengers. The test results are returned in a matter of hours and help reduce crowding and contamination exposure at hospitals. Public screening during the 2003 SARS epidemic, which affected 26 countries © Nir Elias/Reuters Even more ubiquitous are alerts flashing on smartphone screens updating the public on new infections in their area, as well as health officials’ twice-daily broadcasts updating containment efforts. The focus on open communication, coupled with an online system to track those people who have been infected, has helped limit the spread of the virus. The approach appears to be working. South Korea was stunned in late February after a cluster of cases connected to the Shincheonji Church of Jesus, a quasi-Christian sect, saw the number of infections soar to more than 5,000 from fewer than 50 over the course of 10 days. Now, 270,000 tests and countless alerts and press conferences later, the number of daily new cases has declined from more than 900 at its peak to 76 on Sunday, with a total of 8,162 people infected. The country is not yet out of the woods — 100 cases discovered at a call centre in Seoul last week left officials on edge about further clusters. But the success to date reflects that tough lessons have been learnt from the Middle East respiratory syndrome coronavirus, which infected 185, killed 38 and caused public panic in 2015.
In June that year a special WHO committee lambasted Seoul for a series of critical shortcomings including a lack of awareness of the virus among both healthcare workers and the general public, poor infection control measures in hospitals and infected patients failing to remain isolated. Jegal Dong-wook, a professor of laboratory medicine at the Catholic University of Korea Seoul St Mary’s Hospital, says many hospitals have since been equipped with infection control units and negative pressure rooms, which are used to isolate infected patients. The country’s infectious disease guidelines were also overhauled, advising people with respiratory symptoms to first visit a specialist screening centre rather than hospitals. The Mers outbreak also exposed a lack of access to adequate testing kits, which left hospitals scrambling to deal with a rising number of suspected cases. Hong Ki-ho, an official at the Korean Society for Laboratory Medicine, says a new regulatory system was introduced to fast-track approvals for newly-developed testing kits when the nation faces the threat of emergency situations, like infectious disease outbreaks. “One of the companies I know took around two weeks from the application point to its actual use [during the coronavirus outbreak].
This development of test kits and their use for coronavirus was possible thanks to the adoption of that new emergency use approval system,” Mr Hong says. Outside the Shincheonji followers, which have accounted for more than half of South Korea’s cases, public adherence to common sense protective measures like the wearing of masks, using hand sanitiser and limiting human-to-human contact is near-universal, leaving little need for strict government enforcement. A population ready to comply with strict controls has also been key for Japan in containing coronavirus. The government’s handling of the failed quarantine on the Diamond Princess cruise ship and its policy of testing relatively few people have come under heavy criticism. But experts say social and cultural norms that impose self-discipline and obedience to official guidance are one of the reasons Japan has so far managed to limit the number of infections. Hospitals in Taiwan have been restricting people's entry to prevent spreading Covid-19 ©
David Chang/EPA “There is a social norm that you should not cause trouble to other people,” says Kazuto Suzuki, an expert on international politics at Hokkaido University. “If you don’t take care of yourself and become ill, that is taken as causing problems for other people.” The coronavirus outbreak has resulted in the rigorous use of hand sanitisers and washing of hands, while not wearing a mask on the train would attract immediate disapproval. Japan’s obsession with wearing masks predates Covid-19. Sales exploded during the 2009 H1N1 swine-flu outbreak. Mask sales for households are expected to reach ¥35bn ($330m) this year, surpassing the 2009 peak of ¥34bn, according to research firm Fuji Keizai. Hong Kong’s government has been one of the most proactive. The city suspended classes, closed most public facilities and told residents to avoid gatherings when the number of confirmed coronavirus cases was below 20. Hong Kong has turned to a police “supercomputer” normally used to investigate complex crimes to trace potential supercarriers and hotspots in the city following its successful deployment during Sars. Health authorities also regularly update a map showing which buildings Covid-19 patients live in or last stayed at. Residents have been strictly following expert advice to wash their hands and wear face masks, as the memories of Sars, which took almost 300 lives in the city, are fresh in their minds.
But nowhere have the lessons of Sars made as big a difference as in Taiwan. Seventy-three people died from Sars but, as a result of the isolation from international governing bodies demanded by China, it was largely left to its own devices. After the Sars epidemic calmed down, Prof Su — who was then the director of Taiwan’s CDC — spent several months in the US to study its procedures, before returning in early 2004 to overhaul Taiwan’s entire public health system. Taiwan reinforced its capacity by adding dozens of doctors to the staff of the CDC, more than 1,000 negative pressure rooms in hospitals and infectious diseases labs that can host viral testing. “Previously, only the CDC did that, but during an outbreak they can’t cope. So by enlisting labs at medical centres on a contractual basis, we now can test 2,400 people a day, and we can easily expand that capacity just by adding people,” says Prof Su. Taiwan also built a logistics system with stockpiles of basic items — including an inventory of 40m surgical masks.
But the biggest effect came on the political front in a country where politics is usually every bit as partisan as anything in Washington. After frequent quarrels and miscommunication between central and local governments during the Sars outbreak, Prof Su devised a unique management structure: infectious diseases specialists at medical centres across Taiwan are seconded to a body called the Central Epidemic Command Center, which is run out of CDC. The chair of the command centre has equal rank with government ministers. Medical professionals and government officials say the structure helps override politics and ensure a rapid response. Through a sweeping legislative overhaul, Taiwan created a legal basis for limiting civil liberties under an epidemic and allowing it to fine those who violate quarantine rules. All those reforms were tested during the H1N1 influenza outbreak in 2009. “It allowed us to spot things that didn’t work, and many amendments were made since then,” says Prof Chang.
The current epidemic has put the system fully to the test — one that Taiwan appears so far to have passed. Although it has more frequent exchanges with China than almost any other country, with over 1m of its citizens living or working there and more than 2.7m Chinese visiting the island last year, Taiwan now ranks just 50th in terms of confirmed coronavirus cases worldwide. Taipei was alerted to the outbreak in Wuhan early. In late December, health officials started screening passengers on flights arriving from the Chinese city before allowing them to disembark. On January 23 — when the lockdown in Wuhan began — Taipei suspended all flights to and from the city, barred Wuhan residents from entering the country and imposed daily health monitoring for people with respiratory symptoms who had arrived from anywhere in China. On January 26, Taiwan became the first country to bar practically all Chinese citizens from entry. The immigration and health insurance departments linked up their databases, allowing the government to spot people with higher risk of infection. As more information became available about transmission paths and incubation periods, Taipei tightened quarantine requirements. It also cast its net more widely by testing respiratory diseases patients for coronavirus who had tested negative for influenza — an initiative that uncovered Taiwan’s first local transmissions and helped stop them before a community spread developed. International experts praise the response.
“Taiwan is an example of how a society can respond quickly to a crisis and protect the interests of its citizens,” concluded a group of US-based scholars in a paper published earlier this month. But western governments do not appear to have taken much notice. “Maybe there are some health experts hoping that we can help them with testing,” says Prof Chang.
“But with regard to public health management, nobody has been in touch for advice.”
Singapore: city-state has so far seen no coronavirus deaths Despite being one of the first countries outside China to be hit by the coronavirus, Singapore has yet to record a single death. The city state of 5.7m people has had 226 confirmed cases, about half of which have fully recovered and have been discharged from hospital. Thirteen remain in critical condition in intensive care units, while 121 patients are mostly stable or improving. Experts say that the fact most infected individuals have been below the age of 65 helps to explain the lack of deaths in Singapore. “Once the health system gets pushed beyond its breaking point as in Italy, then the number of deaths goes up,” says Dale Fisher, professor of infectious diseases at the National University of Singapore. “It certainly is no magic trick. It’s just that we’re getting the cases, we’re looking after them well, fortunately many have been young and we’ve got strong ICUs”. Ooi Eng Eong, deputy director of the emerging infectious diseases programme at Duke-National University of Singapore Medical School, adds: “Because everyone that has needed a ventilator or other medical support has had access to [them], we have not been overwhelmed.” Clear messaging from the government is one area where analysts say the US and Europe could learn from Singapore. Tough punishments for non-compliance with strict rules have also helped limit contagion. The approach was heavily influenced by the 2003 Sars outbreak, which killed 33 people on the island. Preparations were ramped up as soon as information started to come out of Wuhan — including creating laboratory capacity for mass testing. Most developed countries have the technology to develop tests, says Prof Fisher. “The biggest difference is we went and did it.”
Stefania Palma Additional reporting by Kana Inagaki in Tokyo, Stefania Palma in Singapore and Nicolle Liu in Hong Kong