The Long Road Back to Zero — Taiwan’s Covid Recovery

It was a dramatic collapse. Heading into May of 2021, Taiwan had experienced only 12 Covid deaths without spending a single day in lockdown. But in the middle of that month, the island was suddenly plunged into a vicious and deadly outbreak that has left more than 800 dead. 

At its peak, Taiwan experienced 723 daily cases, and given the lack of testing capacity at the outbreak’s onset, who knows how many there might have really been? Indeed, speaking to Al Jazeera, Taiwan’s former vice-president, the John Hopkins-trained epidemiologist Chen Chien-jen, described Taiwan’s response in the first two weeks of the outbreak as a “disaster”. 

A nighttime scene of Taipei during earlier restrictions. Image: Supplied/Lisa Tsai

But Taiwan adapted and the public never quit. And on August 25, jubilance erupted when the island experienced its first day of zero community cases. It had taken more than 100 days of hard graft to arrive at the momentous occasion. There have since been many days of zero cases and a Delta outbreak that was contained without a lockdown. Now we’re seeing zero after zero and Taiwan once again appears on the verge of elimination.

I’m still pinching myself that we’re here. I admit that at its peak, I doubted it was possible to eliminate an outbreak of this level of ferocity without a hard lockdown. Taiwan’s Level 3, which lasted around 70 days, still allowed ample mobility. Bubbles were self-imposed. There were indoor crowd limits of four people, and nine outdoors, while most work continued on. When we entered Level 2 in late July, Taiwan was still experiencing several untraced cases a day and yet somehow we’ve managed to both ease back into regular life and continue to bear down on the virus. So how has it been done?

Mandatory scanning has been key. Before the outbreak, Taiwan didn’t even have a tracer app. It simply hadn’t been needed. As the caseload exploded, Taiwan’s Digital Minister, the transgender hacker activist Audrey Tang, led a cross-sector collaboration to quickly develop a simple easy-to-use SMS tracer system. 

No app is required. Simply turn on your phone camera, scan the QR code, hit send, and you’ve instantly sent a text message to the CDC. After 28 days, all data is deleted. And anyone can check if their data has been accessed. The Central Epidemic Command Center (CECC) has dealt with cluster after cluster. There’s certainly been no shortage of practice. Scanning has no doubt played an important role. 

A temperature check station at Tiger City Department Store, Taichung City. Image: Supplied/Ema Chang

After long being a holdout, Taiwan quickly adopted rapid anti-gen testing. This is increasingly becoming a part of daily life. Several occupations require regular tests, and all visitors to hospitals must receive them. People can obtain free kits from clinics and test themselves at home. Positive results are followed up with PCR nasal swabs. Taiwan has broken from its long-held practice of targeted testing to engage in mass testing when required. 

And then there are vaccinations. Entering the outbreak, less than 1 percent of the public had received a single dose, no doubt a major factor in the heavy death toll. As soon as Taiwan was in desperate straits, shipments finally began to arrive and vaccinations surged. Hesitancy now seems a thing of the past, despite the worst efforts of the tabloid media. 

Supply, however, is still an issue. As a result, the CECC’s approach has been to prioritize administering as many first doses as possible. Currently, around 57 percent of the total population have received a first dose, while only around 12 percent are fully vaccinated. Taiwan has begun its second major surge of vaccinations and the rate is quickly improving. On September 30, a stunning 439,468 doses were administered, 1.9 percent of the population in a single day! 

A nearly empty Taipei City Hall MRT Station at rush hour. Image: Supplied/Lisa Tsai

Due to the conundrum of Taiwan’s political situation, and despite possessing a strong economy, the island’s vaccine rollout has been heavily reliant on donations. We’ve received donations from Japan, the US, Slovakia, Poland, Lithuania, and the Czech Republic. 

After a long tortured drama with accusations of political interference, a breakthrough was finally reached in obtaining the Pfizer-BioNTech vaccine in July. In a bit of diplomatic fancy footwork, tech giants TSMC and  Foxconn, and the Buddhist Tzu Chi Foundation purchased 15 million doses of the vaccine and are donating them to the government. Pfizer has finally started to be rolled out in Taiwan during the past two weeks. 

Taiwan has also begun to roll out its own vaccine, Medigen. The vaccine has been heavily politicized. The controversy stemmed from the fact that Medigen received an Emergency Use Authorization (EUA) despite having not undergone a stage III clinical trial. It was granted on the basis of immuno-bridging, in which the level of antibodies generated in participants of its phase II trial was compared favourably to those in people who had received AstraZeneca. 

Taiwan’s government was heavily criticized for being the first to authorize an EUA for a Covid vaccine on this basis. The Taiwanese public, one frequently hears, are being used as lab rats. Members of the opposition Kuomintang even tried unsuccessfully to challenge the EUA through the courts. Nonetheless, the rollout commenced with President Tsai Ing-Wen being the first to receive a dose in late August. 

Taipei-based Ron Hanson with his dog Dou Dou. Image: Supplied/Ema Chang

Recently, however, there have been some significant developments that could potentially shake up the discourse around the vaccine. Firstly, we learned that Taiwan’s old nemesis the WHO had included Medigen among vaccines it would sponsor to undergo a clinical trial in Colombia. And then, the Access Consortium, comprising regulators from the UK, Singapore, Canada, Australia, and Switzerland, announced its decision that immuno-bridging studies can now be used to support Covid-19 vaccine authorization.

On top of this, Medigen announced that the European Medicines Agency is encouraging it to conduct a phase III clinical trial in Europe. The EMA says Medigen should go straight to phase III as phase I and II trials have been conducted in Taiwan. The company will finalize its plan and then apply for approval from the agency. If Medigen proves successful, the impact in Taiwan would be substantial, healthwise, politically, and diplomatically. 

How does Taiwan successfully deal with the virus without typically relying on lockdowns? In essence, masks, masks, masks. Taiwan hasn’t wasted a minute arguing about their efficacy. At the beginning of 2020, Taiwan immediately used government funds and military personnel to step up production. It fixed prices, banned their export to ensure domestic supply, and implemented a rationing system to allow equitable distribution and prevent hoarding. 

Digital Minister Audrey Tang famously made the government’s mask data open to the public and invited civic tech hackers to play with the data and design location availability apps. Once the domestic supply was sufficient, Taiwan began donating millions of masks to countries all over the world, a point that is often raised when countries announce their vaccine donations to Taiwan. 

Mask use in Taipei has been 'unflinching', as shown here on MRT (Mass Rapid Transport) Image: Frankie Chang

As the pandemic has gained in intensity and new variants have emerged, mask-use in Taiwan has steadily escalated. In the beginning, there was only a mask mandate for public transportation. By December 2020, they were mandated in almost all indoor public settings. And then when the big outbreak began, masks were mandated in all instances outside the home. 

Despite the heat of peak summer and high humidity, mask use has been unflinching. Seeing a maskless person outside the home is extremely unusual, almost like spotting a rare bird in the wild. Of course, one hears the complaints of the low-risk level of outdoor transmission. But the simple unambiguous policy has made enforcement and compliance straightforward. It plugs all the gaps, as we typically enter in and out of multiple different settings. And it helps the public to maintain a staunch mindset in confronting the virus. Last Sunday, however, the CECC announced it was relaxing the mandate, slightly. Mask-wearing in some outdoor settings is no longer required, as long as social distancing is able to be maintained.

In early September, with the outbreak receding, I decided the time had come to finally take a holiday. I ventured to Taitung on the east coast where I was encouraged to see people maintaining vigilance despite the city having been Covid-free for several months. But while trying to relax at the beach, Taiwan had a Delta scare, that was quickly followed by two others. 

One of Taipei's MRT stations being disinfected during the pandemic. Image: Supplied/Lisa Tsai

The first instance was a high school student who had been infected by his father and then attended school. The school was closed, everyone was put into government-run quarantine centres and tested, but there were no additional cases. Quarantine rules for pilots had been set to be tightened later in the month. The implementation of the new policy was immediately brought forward.

The following day, we learned that two other infected pilots, in a separate incident, had travelled extensively across Taiwan. Alert text messages were sent to one million people who had visited the same locations. As all close contacts tested negative, fears began to ease. 

But on the last day of my holiday, we learned of a cluster at a kindergarten in densely populated New Taipei that was suspected to be Delta. This was later confirmed and my worst fear appeared to be realized, especially as the cluster had spread to an apartment building. All residents of the building were quarantined and tested. Would we be heading back into lockdown? The CECC said they thought they had it under control, and that turned out to be the case. There was no alert level shift and the cluster was contained with 33 cases.    

By my count, Taiwan has now had five brushes with Delta, including two sizeable outbreaks. Thus far it has prevailed, and in a sense, I’m breathing easier with that knowledge. But I’m still haunted by our lapse earlier this year and hope we don’t fall prey to our complacency once again. And so anxiety is par for the course. Each day I wear my mask and watch the vaccination rate inch up. In my better moments, I try and laugh about the situation. What has life become? And then I remember what it is like in so many other countries and remember how lucky I truly am.  

Banner image: Frankie Chang

- Asia Media Centre