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Looking out over the empty streets of Manhattan, the new coronavirus epicenter, we wish the U.S. had learned a few things from Singapore and Taiwan. Here are some of them, and perhaps readers from Singapore and Taiwan can add additional examples.
But first, a look at the numbers. As of time of writing, the U.S. has over 55,000 confirmed coronavirus cases, while Singapore has about 630 and Taiwan has 235. Taking into account their respective population sizes, the U.S. has about 17X the cases of Taiwan, per capita, and 50% more cases than Singapore, per capita, but given the lack of testing in the U.S. and more abundant testing in Singapore and Taiwan, the actual numbers are almost assuredly far higher.
The picture is even grimmer when it comes to deaths. So far the U.S. has over 790 deaths from diagnosed cases of coronavirus, while Singapore and Taiwan each have 2. The U.S. population is about 58X Singapore and nearly 14X Taiwan, so if the U.S. was instead following the trajectory of Singapore we'd expect 116 deaths, or in the case of Taiwan, 28 deaths. Instead, we have a death rate many times those.
It's a sad irony that Taiwan is excluded from the World Heath Organization simply because of China's political objections, when lessons from Taiwan's impressive coronavirus response, as much if not more than WHO guidance, could have helped other countries reduce the human toll of the virus.
1. Early Action
Taiwan sprang into action on New Year's Eve 2019, when China informed the World Health Organization that it had several cases of severe and unknown pneumonia in the Wuhan area. Taiwan's CDC immediately started screening passengers arriving on flights from Wuhan.
Next, on January 12, Taiwan sent a team of epidemiologists and medical experts to China to better understand the new disease. After returning, Taiwan required hospitals to test for and report cases of the novel coronavirus, so that contacts could be traced and quarantined.
On January 26, earlier than any other country, Taiwan banned all arrivals from Wuhan, China. Soon after, flights from most of China were banned, and only Taiwanese citizens and permanent residents were permitted to enter Taiwan from the remaining ex-China flights.
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2. Test as Many and as Early as Possible
The U.S. has been hampered by an extremely slow and late start to widespread testing. Instead of using the WHO's German developed test, the CDC developed its own flawed test that had to be rectified, wasting precious time. While testing is ramping up, at time of writing the U.S. has conducted only ~1080 tests per million, while Singapore has done 6800 tests per million. Only by testing widely is it possible to get a better handle on the actual prevalence of community spread and focus contact tracing efforts.
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3. Free Testing and Affordable Treatment
Singapore and Taiwan both had free coronavirus testing from the outset, and affordable treatment, thanks to their public health systems. In the U.S., some of the early patients tested racked up significant fees, particularly if they had to go to the emergency room. While legislation since then has banned copayments for coronavirus testing, if you go to an in-network provider. But that's only if you're actually tested for coronavirus; if you see your doctor and s/he does other tests to rule out coronavirus but doesn't test you for coronavirus, then you'll still need to pay your usual copay. Needless to say, actual coronavirus treatment in the U.S. is not free and is subject to one's usual copays and the high deductibles that most U.S. healthcare plans have.
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4. Fast Testing
Another key advantage for Singapore has been fast testing. In early March Singapore's Science and Technology Agency and Veredus Laboratories developed a swab test that shows coronavirus results within 3 hours, with an accuracy rate of >99%. Contrast that with the U.S., where it's typically at least 2 days and sometimes longer until someone who's tested hears the results.
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5. Meticulous Contact Tracing
Because coronavirus can be transmitted by those who are asymptomatic and don't yet know they're infected, contact tracing and quarantining these contacts as needed is extremely important in reducing the spread of the virus. Singapore is able to trace up to 4000 contacts each day; given its smaller population, the U.S. would need to be able to trace over 230,000 contacts per day to be on par with Singapore.
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6. Medical Facilities for the Mild Coronavirus Cases
For those who have tested positive for coronavirus and are mildly ill, Singapore has them stay in medical facilities until they test negative (twice) for the virus. This has the advantage of making it less likely they'll infect family members, since the virus often does spread to family members and home quarantine isn't easy, especially in small apartments.
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7. Mandatory 2 Weeks of Self Quarantine for Asymptomatic, with Strict Penalties
In Taiwan, arrivals from areas with significant numbers of coronavirus cases are put under a 14-day home quarantine even if they have no symptoms, and are location tracked using their mobile phone. There are strict penalties for violating quarantine–one man who had arrived from Wuhan and didn't tell the health authorities he had symptoms, yet went to a club the following day, was fined $10,000.
Singapore also has instituted home quarantine for those who test positive but don't have symptoms. SMS links are sent twice a day that must be clicked on to show the phone's location, and for those thinking that they can just leave their phone with someone else, there are even periodic audits when someone comes to your residence to check that you are where you say you are. Intrusive? Yes–but we also have a global pandemic and public health crisis on our hands.
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8. Central Epidemic Commmand Center
Fast and centralized decision making that can coordinate across other government departments is critical when battling an epidemic. Taiwan authorized the creation of its Central Epidemic Command Center after the SARS outbreak in 2003, and authorized it in late January 2020 to take the necessary action against the novel coronavirus, from extensive testing to ensuring sufficient supplies and protective gear for medical professionals to allocating funds to communicating with the public.
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9. Effective Public Education
Educating the public about the virus is crucial to helping ensure people don't panic, but instead take the steps such as hand washing and social distancing, and self quarantining that will minimize its spread. In Taiwan, the government had stations run hourly television and radio public service announcements about how the virus is spread and the importance of thorough hand washing. The public also was made to understand that the virus was not specific to a particular nationality or ethnic group, and risk was determined by an individual's travel history or contact with an infected person.
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