Is Taiwan Prepared for the Next Pandemic?

Despite efforts to enhance Taiwan’s disease preparedness and response capabilities, there are significant and acknowledged limitations to the government’s ability to respond to a future pandemic
Jonathan Schwartz

The past decade has seen the world dodging pandemic bullets. Since 2002-2003, Severe Acute Respiratory Syndrome), or SARS, has left approximately 8,500 ill, of whom about 820 died. Meanwhile, there have been numerous outbreaks of emerging infectious diseases, including Bird Flu (H5N1), Swine Flu (H1N1), H7N9 and Middle East Respiratory Syndrome (MERS-CoV). Each new outbreak brings with it the attendant possibility of serious loss of life and major disruptions to the global economy. Indeed, the World Economic Forum 2012 Global Risks Report identifies pandemics as among the gravest risks facing the planet.

And yet, thus far, each of these potential public health crises has lacked the combination of virulence and infectiousness necessary to cause the kind of outcome public health officials have been both predicting and fearing. For example, in the Bird Flu case, virulence remains quite high (with a case fatality rate of 62.5%), but infectiousness has been quite low, with few if any confirmed cases of human-to-human transmission. By contrast, Swine Flu infectiousness was high (rapidly infecting between 20% and 40% of the global population), with numerous cases of human-to-human transmission. However virulence was extremely low (with a case fatality rate estimated at 0.02%).

As director-general Margaret Chan (陳馮富珍) of the World Health Organization (WHO) has pointed out, we have been very fortunate thus far. But simply relying on good fortune seems most unwise. In a study of emerging infectious diseases from 1940 to 2004 in the journal Nature, a team led by Kate E. Jones found that the frequency of novel viruses has increased steadily through the 1980s, with an average of 5.3 novel viruses each year. Among the factors identified as contributing to the rising frequency (or “disease force multipliers”) are the growing overall human population, expanding deforestation in many parts of the world, increased reliance on factory farms, continued and expanded operation of live animal markets, and greater human mobility. The upshot is that one of these novel infectious diseases may turn out to be both highly transmissible and virulent. It is for this eventuality that we must prepare.

Clearly, global cooperation on pandemic response is essential and, in the aftermath of the SARS outbreak, the international community has moved in this direction. International institutions have been strengthened and expanded with the most obvious example being the WHO’s revamped (2005, entering into effect in 2007) World Health Regulations which increase reporting, information sharing and cooperation requirements for all 194 member countries of the World Health Assembly, the WHO’s decision-making body. However, this alone is clearly insufficient. Global efforts must be buttressed with comprehensive domestic initiatives.

Taiwan has already experienced a number of pandemics, including both SARS and Swine Flu. Furthermore, given Taiwan’s proximity and growing interconnectedness with China (a key incubator and predicted source of future pandemics) the likelihood that Taiwan will face a future pandemic seems high.

In a report published by the Taiwan Centers for Disease Control (CDC), the Taiwanese government anticipates that a future pandemic striking Taiwan could result in more than 3 million people requiring medical assistance and a substantial number of deaths with high economic costs.

According to the Health Belief Model, perceived susceptibility, risk and benefits drive individual behavior in the context of pandemic threats. Thus, populations that have not directly experienced a pandemic do not take the threat seriously and are therefore unlikely to be prepared while those that have experienced a pandemic can be expected to take the threat seriously and invest in preparation. As predicted by this Model, Taiwan, having experienced two major pandemics in recent years, should be expected to take the threat of a future pandemic quite seriously. In fact, Taiwan has taken the threat of a future pandemic seriously, as is reflected in the many efforts it has made to develop the institutional infrastructure necessary to respond to future pandemic outbreaks.

Perhaps in its most significant move, Taiwan has responded by updating (in 2009) its Communicable Disease Control Act (傳染病防治法), which provides the basis for any response to a pandemic. The Act confers broad powers on the Department of Health and other “competent authorities” to take such actions as controlling or prohibiting school attendance, business meetings and public gatherings while limiting or canceling public transport. The lead agency in the case of an outbreak is the Central Epidemic Command Center (CECC) which brings together top officials from all relevant branches of government, including the departments of agriculture, health, commerce, transportation and foreign affairs and in certain circumstances may implement relevant disease control measures jointly with the national defense mobilization preparedness system.

However, despite these and other efforts to enhance Taiwan’s disease preparedness and response capabilities, there are significant and acknowledged limitations to the government’s ability to respond to a future pandemic. For example, over the past 6-7 years, the CDC’s budget has been in absolute decline and from within the budget, the percent allocated to epidemic control and response has declined as well. Furthermore, there remain serious gaps in Taiwan’s pandemic preparedness arising from the limited number of public health and CDC officers. A sometimes confrontational and sensationalist media, as well as growing public distrust of government, risk compounding the problems.

What more can be done to strengthen Taiwan’s preparedness?

One potential solution to what seems to be a predictable, even inevitable, crisis can be found in enhanced state-society cooperation. Promoting initiatives that draw on a combination of state resources and groups in society who can cooperate to minimize and control the impact of any future outbreak is one promising area. Taiwan’s governing structure includes, at the lowest level, an entity that is neither government nor society but works as a facilitator between the two — the Li Zhang. In the Taiwanese bureaucratic structure, the Li (neighborhood) is subordinate to the district which in turn is subordinate to the city or county (Shi 市 or Xian 縣 depending on location). In Taiwan there are approximately 7,850 Li. Below the Li are approximately 148,600 Lin, or blocks. The average Li Zhang oversees approximately 5,800 people whereas the Lin Zhang, who is appointed by the Li Zhang, is usually responsible for between 100-300 people. Throughout Taiwan, in both urban and rural settings Li Zhang and their equivalents are elected by their own neighborhood members and act to transmit information between the state and the local community while obtaining and providing services for the community members. In most cases the Li Zhang are long-time members of a community familiar with its patterns and many if not most of its residents. This is not a paid position, though the Li Zhang does receive a small budget from the state to cover the costs of services provided. Among the services the Li Zhang may provide are organized group excursions and neighborhood beautification initiatives. The Li Zhang also provides notices regarding upcoming events for seniors, public health nurse visits, as well as general help with resident complaints.

However, overall the Li Zhang’s responsibilities remain ill defined, leaving Li Zhang free to provide a bare minimum of services or to offer an ever-increasing range of services. Given their unique place situated between the state and society, with their knowledge of their own communities and their relationships within those communities, the Li Zhang represent an important potential resource in preparing for and responding to emerging novel infectious diseases.

A limited survey of Li Zhang activities during the 2002-2003 SARS outbreak illustrates their potential to assist state efforts in pandemic response. During SARS, Li Zhang transmitted public health notifications from the state to the community, worked with local public health officials to disinfect communities where necessary, and assisted in enforcing quarantines on potentially ill residents (including providing food, face masks, and thermometers to those in quarantine). Perhaps most importantly, the Li Zhang were able to draw on their position in the community to foster trust, confidence and cooperation to achieve the shared goal of effective pandemic response.

Notably, the Li Zhang’s responsibilities are not, in general, clearly delineated. Li Zhang can choose their own level of engagement in providing services, including those related to pandemic response. During SARS, some Li Zhang were actively engaged while others limited their participation in disease response to the bare minimum. This lack of clearly defined Li Zhang responsibilities provides a real opportunity. By clearly mandating cooperation with public health officials at the local level among Li Zhang responsibilities, and providing the training required to carry them out, the Taiwan government can draw on an existing local level resource to greatly enhance pandemic preparedness and response. The Health Belief Model predicts that this is a goal likely shared by the majority of Taiwanese people. As such, with sufficient preparatory work, we should anticipate support for such an initiative at the local level. Given the likelihood of a future highly virulent and infectious pandemic arriving in Taiwan, there is little time to lose.


Jonathan Schwartz is Associate Professor of Political Science, Director Asian Studies, State University of New York, New Paltz

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