On March 2, 2017, Taiwan suffered its first Avian Flu-related (H7N9) death. The man contracted the disease while visiting China, and died despite a month of intensive treatment in Taiwan.[1] This is but one example of the increasing threat of global pandemics, a threat that has sparked concern among government officials and the general public.[2] Driven by these concerns and its past experiences with pandemics, Taiwan has experimented with new approaches to preparedness and response. Given its efforts, Taiwan should be viewed as providing a useful example of innovative pandemic response.
Pandemics have come and gone throughout history, but over the past 15 years in particular there has been growing awareness that conditions are becoming increasingly ripe for a significant globe-spanning outbreak. Indeed, over this timespan, there has been no shortage of pandemics, though none yet exhibiting characteristics of virulence and infectiousness that could in combination result in major global disruption.
The 2002-2003 Severe Acute Respiratory Syndrome (SARS) outbreak originating in China was a shot across the bow – a warning of the potential damage pandemics may cause. The SARS case-fatality rate (the number of people who sickened and died) was 14-15 percent overall and over 50 percent for people over 64 years of age. These numbers are distressing, and yet at the conclusion of the outbreak the WHO identified only 8,447 confirmed cases and 916 deaths worldwide. Of course, the impact of SARS extended well beyond infections and case-fatality rates. SARS had a significant psychological and economic impact as well. Indeed, the World Bank estimates that SARS caused a global GDP decline of $33 billion over its 7-month span.
That even the relatively limited SARS outbreak could have such a massive impact underlines the potential devastation of a highly virulent and infectious disease. For example, if an equivalent to the Spanish flu (which lasted from in 1918-1919, infected one-third of the then global population, and killed between 20-50 million) were to occur today, it would potentially kill over 100 million people worldwide and cut global economic output by over $3 trillion. Since SARS, we have experienced Highly Pathogenic Avian Influenza (Bird Flu), swine flu, Ebola, Middle East Respiratory Syndrome (MERS), dengue, Zika, and continue to fight AIDS worldwide. Again, while none have yet risen to the level of a globe spanning, easily transmissible, and virulent pandemic, each has underscored the potential threat.
The international public health community, led by the World Health Organization (WHO), continues to update and improve existing protocols, policies, and early warning systems, in order to facilitate cross-border cooperation. However, the WHO also acknowledges that successful pandemic response requires effective domestic response capacity, something that no country yet possesses.[3]
The Health Belief Model suggests that perceived susceptibility drives individual behavior as regards pandemic threats. Only populations that have experienced a pandemic are likely to take the threat seriously and invest in preparation. Having experienced major recent pandemics, Taiwan—as predicted by this model—has taken the threat of a future pandemic seriously and made a variety of innovative efforts to develop effective response capabilities.
One notable initiative taken by Taiwan conforms with the “whole-of-society” approach to pandemic response. States generally focus on comprehensive public health plans, high technology medical tools, physician care, vaccination and immunization protocols and public awareness building. These are all essential, and yet alone are inadequate. In line with the whole-of-society approach, research I conducted finds that improved outbreak control requires that states also invest in cooperation and trust building with local communities. This involves drawing on local actors to supplement government actions by distributing resources for disease control, disseminating information to educate the public, mobilizing volunteers, and ensuring community interests are represented while fostering equitable access to resources and trust in government institutions.
Taiwan’s government invests in traditional, state-led pandemic preparedness as described above. But in addition, the Taiwan CDC works closely with schools, elderly care facilities, prisons, and international entry points to track and contain as necessary diseases with pandemic potential. The Taiwan CDC also works with local hospitals and the private sector (e.g. hotels) to identify and treat potential cases early on. Perhaps the most important innovation, however, has been the government’s work with societal actors.
In line with the whole-of-society model, Taiwan’s government has invested in close coordination between public health officials and community leaders. Focusing on the li (里) or neighborhood level, the Taiwan CDC has been training and supporting neighborhood wardens, known as li zhang (里長), in epidemic-related prevention and control activities. The neighborhood warden is a non-state actor residing below the lowest level of government, who functions as an elected liaison between his/her neighborhood (averaging 5,800 residents) and the state. Usually a longtime resident of the community and familiar with its residents, the warden represents the community’s interests to the government, while also facilitating government resource deployment locally.
Recognizing the potential for wardens to play a constructive role, the Taiwan CDC in 2016 initiated a program to train wardens in dengue prevention and response. Focusing on Kaohsiung and Tainan, this initiative was a response to the historically unprecedented 2015 dengue outbreak in which these two cities suffered over 42,000 infections. The wardens cooperate with the CDC and local public health officials, foster community trust and offer an avenue to convey important outbreak-related information, mobilize the community, and engage in activities that diminish pandemic risk.
A recent example illustrating the effectiveness of this approach is the Taipei CDC’s cooperative work with wardens during the November-December 2016 Taipei Dengue outbreak. Working together with public health officials, the wardens identified potential and existing breeding grounds for dengue-bearing mosquitoes while also providing information to their communities at the individual level on how to prepare for and avoid infection.
This cooperative effort has been identified by Dr. Yen Muh-yong, from the Taipei City Hospital Division of Infectious Disease, as playing an important role in Taipei’s successful dengue response.[4] Although it would be incorrect to attribute successful outbreak containment solely to the contributions of wardens, it is clear that they played an important role in supporting response efforts.
The main point: Taiwan’s example of outbreak prevention and containment is instructive, as equivalents to its neighborhood system that exist throughout the region. Indeed, they can be found in China, Japan, Vietnam, and Singapore (among others). As the number of outbreaks grows, these countries would benefit by drawing on Taiwan’s experience with whole-of-society pandemic preparedness and response.
[1] ProMED-mail. PRO/AH/EDR> Avian influenza, human (28): China (GX) Taiwan, H7N9, mutation. ProMED-mail 2017; 02 Mar: 20170302.4874114. <https://www.promedmail.org/post/4874114>. Accessed 02 March 2017.
[2] Kate E. Jones et al., ‘‘Global Trends in Emerging Infectious Diseases,’’ Nature 451 (February 2008): 21, 990–94, doi: 10.1038/nature06536.
[3] Jonathan Schwartz and Muh-yong Yen “Toward a Collaborative Model of Pandemic Preparedness and Response: Taiwan’s Changing Approach to Pandemics,” Journal of Microbiology, Immunology and Infection (2016), doi: https://dx.doi.org/10.1016/j.jmii.2016.08.010.