A Taiwanese family doctor in COVID-19 – would you give up your freedom to be free? The role of surveillance

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.

Date of interview: 22nd April 2020

Number of confirmed cases at time of interview: 427

Number of deaths at time of interview: 6

Population: 23.8.million people

This week I have interviewed Dr Pinghsun Chang who is a family doctor in a public hospital in Hsin Chu city, which is an hour away from Taipei. He spreads his time between outpatient clinics, palliative care, home visits and an occupational health role in a factory. I was so keen to talk to Pinghsun because we hear about the exemplary way that the Taiwanese government have managed COVID-19 that, despite being neighbours to China, has a death rate still in single digits. How was this possible?

First of all, I ask Pinghsun to describe to me how primary care works in Taiwan. Family doctors can work in both hospitals and in community clinics and, like Japan and South Korea, has a relatively young family medicine movement. Patients still have direct access to specialists and, as there would be when there is no gatekeeper role, there are concerns about inefficiencies within the medical practice. Each Taiwanese resident has a National Health Insurance Card which gives them access to health care and it is this card that will become crucial in the COVID-19 response. Clinicians use this card with a specific card reader to access the patients’ records, medication lists and medical imaging. I know that Portugal has a similar system where patients carry their own card and, personally, I quite like it as it means that the patient has to take some ownership of themselves but I appreciate that some colleagues would argue that it was a data disaster waiting to happen or that it would disadvantage those prone to losing things.

At the beginning of the pandemic, when there were barely whispers in Wuhan, the Taiwanese central government picked up on information that there was a SARS-like illness being seen in China and took it upon themselves to investigate further. Unfortunately, information was difficult to come by but Taiwan – who like Hong Kong were deeply and tragically affected by the SARS outbreak in 2003 – started to take some serious measures. They investigated through their own networks in China and, even though this coincided with Chinese New Year which is a national holiday, the Centre of Disease Control (CDC) started to distribute Personal Protection Equipment (PPE) to clinics and hospitals. They quickly implemented a ban on exporting masks for the foreseeable future which is a big deal because they are the 2nd or 3rd largest manufacturers of facial masks in the world. This could explain why there was such panic-buying in other Asian countries (this restriction has since lifted and Taiwan has sent out 10 million masks worldwide this week). They collected data on the number of isolation rooms in hospitals and designated individual institutions to high- or medium-risk patients. This I find interesting because, in the UK, a hospital would be split as red (hot) areas and blue (cold) areas but sending COVID patients to one particular hospital seems to be more prevalent in Asia. I ask Pinghsun about the SARS outbreak in 2003 and he told me that patients were transferred to one specific hospital where the medical team had to live on site and were forbidden to leave. Unfortunately, like Hong Kong, the mortality rate was high (27%) and a large number of medical personnel had been infected and had also died. It is no wonder that Taiwan was on their guard when they heard the first rumours about COVID-19. There is a political context to this as well. Taiwan has been overshadowed by China politically for decades and have even been blocked by China from being a member of the World Health Organisation. This general distrust of their neighbour and also of the WHO perhaps spurred them to act quicker and more decisively based on their own intelligence.

So how has Taiwan managed to keep their confirmed cases below 500? It appears that they take contact tracing very seriously. If one person tests positive, they trace everyone that they have been in contact with for more than 15 minutes in the last two weeks. Remember the National Health Insurance cards that I mentioned earlier? The government merged the data from these cards with immigration data and therefore was able to identify who had returned from abroad and was able to put them into active quarantine for 14 days. They are designed to alert a doctor that they are seeing high-risk patients who have returned from abroad if the medical cards are swiped in clinic. Like most East Asian countries, masks are worn before this pandemic hit and these cards are used for their fair distribution amongst the public. Cards which end in an odd number get their rations on certain days of the week, those with an even number on the other days. And people comply.

The use of mobile phone technology is also interesting. A person will receive a text message if they enter a high-risk area; if they are supposed to be under quarantine and leave their house, they will receive a phone call to confirm whether they are still at home or not; and if they don’t answer, the police will politely knock on their door. If you get caught outside, the starting fine is 3000 US dollars which rises for every hour that you have been outside. This level of observation could feel quite oppressive but Pinghsun tells me that the Taiwanese are fully aware of the severity of this disease and the consequences if they don’t obey. I’ve mentioned this before but East Asia culture has a strong community vibe and it is part of every day life that you behave modestly, respect the rules and accept that you are being watched by your community members. The ability of my East Asian colleagues, who have been scarred by SARS in 2003, to accept harsh changes for the greater good really stands out to me as an essential component of their successful response rather than a singular government action. I do have some concerns about the long-lasting effects of surveillance and suppression of civil liberty and Pinghsun also has some concerns about the future generations being tagged but this is not the time to be worrying about this. The extreme of this can be seen in Hungary where they have surrendered to autocracy which may be a political step too far.

I also ask him about his Vice-President who is a trained epidemiologist. Surely having a medic at the top table being able to implement public health measures with full political power must be the reason why they have been so successful, right? Pinghsun doesn’t think it is down to one man. In fact, apparently, a large proportion of the Taiwanese government is made up of those with a medical of public health background. He tells me that this is historical because, when Taiwan was a Japanese colony, the Taiwanese people were not allowed to go into politics or finance so many of the brightest and best trained in medicine before swapping over. Is this another key to their success?

We finally wrap up by swapping a few stories about COVID-19 from our own countries. In the UK, we have been plagued by some fake news that mobile phone 5G masts have caused the spread of the virus leading to about 100 masts being vandalised nationwide. This has been propelled by certain social media influencers including the Hollywood actor Woody Harrelson. Pinghsun tells me that, in Taiwan, there was a law passed in 2018 against people spreading fake news following interference from China in their general elections. If anyone tried to spread false stories without confirming it first, they would be fined a penalty. I feel that even a split second of thinking before pressing the ‘share’ button may be enough to slow the spread of what is essentially a dangerous conspiracy theory. This is evident even more so in the U.S where there has been some concerns about fake news being spread by certain global economic giants who are wanting the U.S to be hit by coronavirus the hardest to make their economy suffer. But I think I’m entering the territory of propelling a conspiracy theory about a conspiracy theory and will stop here before it gets too meta!

He also verifies a very funny story about several criminals from Taiwan, who had escaped to China, turning themselves in to the authorities after a decade of exile because it is currently safer in Taiwan. To be honest, I’m not surprised and, during this interview, I get quite jealous of Pinghsun because, as we are talking, he is taking his children by car to pottery class which is a far cry from my lockdown life baking banana bread. Daily life doesn’t seem to have been disturbed much in his city and neither has his healthcare system. He feels that the vigilance shouldn’t stop and that there will be outbreaks that will need to be quashed quickly if it arises. He’s bracing himself for the long game, maybe one to two years with a vaccine as an exit strategy. As with all these things, who knows?

We finish on the story about the public apology made by the Taiwanese navy for not following protocol when they had symptomatic sailors on board. I ask him why this was such a big deal and he tells me that there are suspicions that the sailors, even though on a mission to Palau, had secretly stopped off at another country and that this has unearthed a cover-up. It is funny for me that having spent an hour talking about the transparency and open surveillance of the Taiwanese people in this response to COVID-19 that we end up on another conspiracy theory!

Thank you to Dr Pinghsun Chang for this eye-opening account. I wish you and your colleagues good health and safety and I look forward to the day that I can eat all the dumplings in your country.

Jiufen in Taiwan which is rumoured to be the town that the Miyazaki film Spirited Away was based on. I’ve not been to Taiwan but it’s very high on my list of places to go.

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