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Steven Goldstein: Good morning, good afternoon, good evening, wherever you are. My name is Steven Goldstein and I'm the director of the Workshop at the Fairbank Center at . And I'm very pleased today to moderate a round table on the COVID-19 virus and the experience in Taiwan. Let me just start off with a few thoughts. Taiwan appears to be the land of miracles. In the 1970s, when I was a grad... well, I was more than a graduate student, the Taiwan miracle was the economic transformation that took place in Taiwan, after the establishment of rule on the Island. In the two thousands, or in the turn of the 20th century, the Taiwan miracle was a political miracle. It was the democratization of an authoritarian regime.

Steven Goldstein: And now people are talking of a third miracle Taiwan's response to the COVID-19 virus. You see the more I read about it, the more I see terms like gold standard being used to characterize the Taiwan experience. Miracle's not a good word, because every one of those miracles, including the miracle today has been the result of political leadership and societal participation. They're the result of policies led by political leaders with the participation and cooperation of the people. This was unquestionably the case in the first two miracles. And today it's becoming increasingly clear that the same holds for the present miracle. Political leadership, societal effort, combined with technological capabilities, social policies, government institutions have all played central roles in Taiwan's response.

Steven Goldstein: Today we're going to look at that response and we're very fortunate to have some excellent guests to take part. From Taiwan, we have Jen-Hsiang Chuang, who is the Deputy Director General of the Centers for Disease Control. We have Steven Kuo, President of National Yang-Min University and former Head of the Centers for Disease Control. We have Winnie Yip on the Harvard side, who is a Professor of Global Health and Economics at the Harvard T.H. Chan School of Public Health and Bill Hsiao, William Hsiao, who is the K.T. Li Professor of Economics, also at the Chan School of Public Health. I've asked Professor Yip to make a few introductory comments. And then we will go to a round table format among the participants and end with questions from the viewers.

Steven Goldstein: When that time comes, or during the talk if you'd like, just simply press the Q and A tab at the bottom of your screen to submit questions. You may choose to remain anonymous, but otherwise please provide your name and institutional affiliation. And finally, we expect to receive more questions than we're going to be able to answer, not that we won't be able to answer, but the constraints of time. I think with these people, we should be able to answer practically anything. And so we expect to receive more questions than we'll be able to answer. And I hope you'll understand if your question is not introduced. So Dr. Yip, would you like to begin?

Winnie Yip: Great, thank you Steve. Good evening to our friends from Taiwan. As Steve said, Taiwan is holding up now as the gold standard in the response to COVID-19. So we're delighted to have this opportunity to hear from you what you do and share lessons for others. Now, for the audience who may not know, with a population of 23 million in Taiwan as of June 1st, the total cumulated cases of COVID is only 443. While we wish it is zero. But if you look at what is happening in the United States and many other countries, being able to control it at 443, and the number of deaths is only seven so far, it is very The Challenge of COVID 19 The Taiwan Experience (Completed Page 1 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. admirable and we wish every country could do it. And you were able to, if I would quote what my epidemiologist colleague would say, you were able to manage the situation and control the growth of the number of cases.

Winnie Yip: So it doesn't go into exponential growth. Because once it goes into exponential growth, it is out of control. They're many things you cannot do. And I think you are very successful by preventing that in happening. And because of that, you also avoid the shutting down economy, shutting down schools, shutting down society, which of course have major consequences and therefore much more difficult in recovery. And also your healthcare system do not get crushed if I may say so, because you were able to really intervene early and also fast. So again, as my epidemiologist friend here would say that with infectious disease, it's always about speed, speed, speed. And in this particular case, because COVID's transmission is also asymptomatic. So the other key word is test, test, test. And Taiwan seems to be able to adhere to speed, speed, speed and also do test, test, test.

Winnie Yip: So I think that it would be wonderful if we can hear from you. If I may ask that Dr. Chuang to share with us briefly, what are some of the strategies that Taiwan introduced especially in the early phase? I understand that even on December 31st, when WHO was informed by the Chinese government of COVID-19, you already started some measures on border control and then gradually take a very nuanced approach to expand it. And therefore... and I'm sure it is rather difficult because of the huge volume of travel between and Taiwan. The large number of people that actually live in Tai... China, and work in China and around Chinese New Year. And, you also deploy technology beautifully. And you say in the database that multiple database, including the national health insurance database, the immigration database to help you with case identification.

Winnie Yip: So it will not be just a due justice for me to say it. So we are delighted that, we would love to hear from Dr. Chuang. What are some of the key strategies that you adopt for... that allow you to present the epidemiological curve to become exponential, if I may say that? And then I'd like to invite Dr. Kuo to perhaps list three lessons for other countries. Now, before the talk, actually Dr. Kuo reminded us that today Dr. Chuang is the spokesperson for COVID response. 17 years ago he was the spokesperson for SARS. So we are very delighted to have both of them here. So with that said, can I invite Dr. Chuang to just give us a brief overview of what you did and then Dr. Kuo?

Jen-Hsiang Chuang: Everyone, thanks for inviting to participant in this online presentation, so for Taiwan experience in combating COVID-19. So I will share our experience first. I think we have a very rapid response for the early warning. For example, on the December 31, 2019, we learn from the PTT, that's a large online forum in Taiwan, there had been at least seven case of typical pneumonia, and they were isolated in Wuhan, China. So at that time, because we have some thoughts on this news. So we sent emails to WHO and Chinese CDC for the further information. So we also implement the onboard quarantine of our passenger from Wuhan at the same day. And since that day, we had a press conference every day to communicate the everyday situation with our public and share our public and journalists about what's the situation in Wuhan.

The Challenge of COVID 19 The Taiwan Experience (Completed Page 2 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here.

Jen-Hsiang Chuang: Although we only got the some, very formal report from the China CDC. But we report such kind of information to the public but we also to convey our... some kind of thoughts about this information to tell our people to know. Because we don't know, is this human to human transmission or not. We also don't know how's the transmission, how quite easily transmit from the animal, or is there any source of the invasion agents. So we are trying to analyze such kind of information with our public every day. Then we also try to establish our diagnosis kit after the China release their genetics frequency. So January 15, we have listed this disease as a notifiable disease, according to our Communicable Disease Control Act.

Jen-Hsiang Chuang: And on the January 20, we activate our Central Epidemic Command Center. So let's us can be mobilize all our resources and course our department effort to combat this disease. So it's fortunate two days later, we gather first cases of the no... COVID-19 case from the Wuhan. So it demonstrate our ability to diagnose the disease. And later we use the contact tracing. We have... we use our... Because in past years, we are trying to contact tracing every minor case. So if there is any minor case occur, we use our state personnel to try to investigate every potential contacts and try to monitor. Is there any case occurred during this follow up period? So in the past years, we use the contact tracing for the TB, measles of the control such kind of disease.

Jen-Hsiang Chuang: So happen for the COVID-19, it's just like a very good experience for us to do it. And we also try to... our expert panel also instruct us how to update our definition of case frequently. So in the first beginning, we only focus on the Wuhan, traveling history from the Wuhan. Then later we are to expand our travel history, such as Hubei or from other place. So, and also include other symptom into our case definition. And I also want to share our another experience is, we have the retrospective testing of the negative cases of the Influenza with the severe complication on the 15th of February.

Jen-Hsiang Chuang: So because of this strategy, we got the case 19 of the COVID-19 in Taiwan. And this case occurred in the hospital and also transmit it to his family. So it's very fortunate for us to catch this case very early to avoid the further transmission around the hospital. And so another thing is the digital. I'd like to share, we have some kind of advanced technologies such as, we combine our National Health Insurance data with our migration travel history. So when a patient go to the hospital, when he presents his National Health Insurance card into for the clinician. The doctor can notify, is this patient have any travel history in the recent 14 days to alert the doctor for is this possible potential case of COVID-19.

Jen-Hsiang Chuang: And we also have another digital smart technologies, like digital friend system for the people underlying the current home quarantine. Because we use this cell phone, the signal from the cell phone and to check with the nearby cell sites. So if these people have out of the range of the designated house, then the police will call and alert and try to figure out if this person did not obey our home quarantine rule. So the police will go to check this situation, and if this person also... break the rule then he will have some-

Winnie Yip:

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Penalty.

Jen-Hsiang Chuang: penalty for some money. So at least some introduction of our current strategy for the COVID-19.

Winnie Yip: Fine, thank you very much. There's so much there that I'm sure that we can come back to some of those during the discussion and the Q and A as well. Dr. Kuo, three lessons?

Steven Kuo: Well, first of all, I'd like to thank to invite me to join you. Well, I'm not quite sure I can say any kind of lessons that are useful that people can learn from, but indeed we are kind of happy and proud of the fact that we are one of the very few success story. Like you said, I'm not quite sure it's a miracle but at least we are happy, the fact that we can control the outbreak in the very early ons. And I think the result like Steve and Winnie said is really a combination of a speed, solidarity... technology and trust, leadership, and perhaps luck. And actually it's mainly luck I would argue. For instance we have a Vice President who happened to be a top epidemiologist.

Steven Kuo: And he also before Health Minister who was appointed as the minister in the middle of SARS outbreak in 2003. And we are lucky that we have a Health Minister who served as a commander-in-chief and who happened to be a great communicator. And that's luck, I would say. And also it seems to me that among all the cases we have there is none, is we can call it a super spreaders. And that's probably luck. And perhaps most importantly, we are lucky that we have a single payer National Health Insurance Program in place for 25 years, that Professor Hsiao helped to build. And that is really serve as a foundations, to link and to provide a affordable cares and a trust to the people. And also because the information technology and the infrastructures, and so that serve as a platform. Like you said they can link all the data set together.

Steven Kuo: So I'm not quite sure, so I can say there's three or four lessons we can share with the other countries, but I pretty sure speed is the number one things. And perhaps test, I will probably argue, mass testing is not the idea. So I have problems with the WHO saying the key is test, test, test. I will probably like the WHO say it's mask, mask, mask, instead of test, test, test. And definitely risk communication is very important. I think Dr. Chuang and the commander-in-chief, Minister Chen spent hours everydays, talking to the public in the early press conference. And it really helped. It calm the people, provide the right and coherent, consistent message to the public. And so I think all of them is, would be probably the reasons that we have the successful results so far.

Winnie Yip: Great, thank you very much. I kind of have to ask a question before I turn to Professor Hsiao. To ask some question, is this test, test, test versus mask, mask, mask. They maybe I'll cast the question a little bit broader, that is one of the challenge of COVID-19 is that transmission can be asymptomatic, which is different from SARS, which makes prevention much more complicated. What would you, can say advise, or you can say reflection, given these characteristics of COVID-19, what would be some of the more

The Challenge of COVID 19 The Taiwan Experience (Completed Page 4 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. effective or nuanced strategies that also can be deployed very quickly? Here in the U S we talk about tests, but then we also are running through all the blunders off not having the right tests or, and so I'd love to hear from both of you, what are your thoughts on the fact that COVID is asymptomatic and given that characteristics, what would you recommend?

Jen-Hsiang Chuang: In my side, I think we did the testing for isolating the case from their contacts. And after we identify the cases and the contacts, the case will be treat in a hospital and the contact will be home quarantined for 14 days. So if there is any asymptom case, they also within their home will not spread to others. And this also apply to the inbound traveler. So if they, I got the illness from the other country, and after the entry into Taiwan, they also have the 14 days of quarantine. Then it's not so... is he asymptom or not asymptom? You will be quarantined and will not transmit to other person. And finally, we also - because in Taiwan, mean it's air pollution is very severe. So many people wear layer face mask frequently. So in Taiwan, healthy people also were the face mask. And it's, I think this time we can combat the COVID-19 very successful wearing the face mask. May be also some kind of good measure to combat this disease. But for some other country they don't, they may think wearing the face mask may be very strange. So it may...

PART 1 OF 4 ENDS [00:26:04]

Jen-Hsiang Chuang: It may be very strange. So, it may be did not work very well. So, that's my opinion.

Steven Kuo: Well, I'd certainly agree. You know, it's very important to understand that SARs is quite different from COVID because COVID later on has been proved that can transmit asymptomatically. Well, actually in the early on, we have that question is whether or not they really like that. And actually people are like Tony Fauci in the very beginning argue probably asymptomatic transmission is not really the drivers of the outbreak. And, you know, the argument is the same in Taiwan early on. So that I say, I mean, so it's kind of a lucky for Taiwan because people are really kind of scared during the SARS outbreak and because they are used to wear masks either because the air pollutions or because people, you know, riding bicycle in Taiwan and they are used to it.

Steven Kuo: And, but anyway, you know, people kind of believe the mask can help and so in the early on of the Covid outbreak actually we have the problem of a mask shortage. So the government has come up with some measures to rationing the mask in the very beginnings, just fortunately that the supplies catch up and so we don't have that problem, but the asymptomatic transmission is somewhat key in this outbreak, definitely different from the SARS now.

Steven Kuo: So the question is whether or not the test can solve the problems. Okay. I would argue that in Taiwan, although we didn't do the mass testing, but we do the test precisely, or I would call it precision testing or precision public health instead of trying to do the mass testing, like all, you know, locked down a country or a blanket order to ask the public to stay at home. We are doing more precisely. We are using

The Challenge of COVID 19 The Taiwan Experience (Completed Page 5 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. scalpel instead of a hammer, so to speak. And so this has to definitely have some positive effect on the outcome of the outbreak. And definitely like you say, I mean, it didn't hurt that economy that much.

Winnie Yip: Great, thank you so much. Lots of lessons, especially to the US to learn from and understand that you actually doing a lot of work to precisely identify the population into different risk groups, and therefore you can be much more targeted and nuanced in doing testing or quarantine and so on. So let me turn to Professor Hsaio whom, I think has lots of questions for both of you.

WIlliam Hsiao: Well, my first question is that you emphasize speed is the key to contain this virus. Can you share with the audience to have a speedy reaction? You have to be prepared, and you did the preparation for such kind of outbreak you learnt from SARS experience? Can you tell us a little bit more in detail what preparation you had done?

Steven Kuo: Okay. Okay. Well actually like Dr. Chuang just mentioned that well in the end of the last years, right, we can pick up the signal from the social media. Well, how we can do that? You know, is precisely because of the SARS outbreak would have put in place surveillance systems, which actually is run by Dr Drun. You know, he is then experts of a bioinformatics, and I'm lucky that I can recruit him from National Yang- Ming University to Taiwan CDC. And so, in a sense, after SARS outbreaks, we put in place surveillance systems, well, maybe attempt Dr. Drun can elaborate a little bit about all the systems we have. And the system, the monitoring surveillance system is not only monitoring and collecting the data from our hospital or clinics or ER, or you know, or the national health insurance. They also monitor social media and the news report around the world.

Steven Kuo: And that's why we have the capacity to pick up the signal very, very early on. And once we pick up the signal, as I understand, we immediately sound the alarm. Okay. So everybody knows there's something. And because like you just mentioned, you know, people are scared during the SARS outbreak. So in a sense the society is a human, a humanized in a sense, you know, by the SAS outbreak. So when they heard the term Coronavirus, guanzhuang bingdu, they are scared. And so they are voluntarily to collaborate or, you know, they change their behavior immediately. And that is one of the examples that we prepare for the next pandemic, by putting in place a surveillance system that I would say is, you know, something we are really kind of proud of. Yeah.

Jen-Hsiang Chuang: I will introduce our mental officer to answer this question.

Angela Wang: Hi, right. I'm Angela Huang. I'm one of the medical officer here at Taiwan CDC. So with, regarding to the other preparation that we've done over the last seventeen years, since 2003, the SARS outbreak. I think one of the things that Dr. Kuo mentioned is very important is our rumor surveillance, and that was put into place by Dr. Drum, I think in addition to that, we have over the years, we've learned the importance of having our laboratory capacity. And so that was built up over the last 17 years or so since our last

The Challenge of COVID 19 The Taiwan Experience (Completed Page 6 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here.

SARS outbreak. So, you know, we were able to quickly get our laboratory testing capacity and get that ramped up and have that. Our central reference laboratory acquired the testing kits, or actually they, they set up their own protocol for testing and very quickly got our contract laboratories to be involved so that we can increase our laboratory capacity.

Angela Wang: So by doing that, slowly expanding our laboratory capacity. Right now we can test about 5000, sorry, 6000 specimens a day and that capacity is all over the older the island. So I think that was one of the important things that we were able to diagnose and identify patients very quickly. Another thing is that, you know, during SARS, one of the important things was that the disease was transmitted from patients to hospital healthcare workers. So one thing that was important, an important lesson that was learned during SARS is the importance of having each hospital needing to have their own infection control protocol in place. In fact, this is a very, very much stressed throughout the country that we also have a hospital network that is specifically trained to deal with things like this so a pandemic. So, and, you know, in the last 17 years we have H1N1, we've had Ebola, we've had H7N1, we've had MERS and all these diseases, whether they came to Taiwan or not, we were able to activate and practice our hospital network.

Angela Wang: So each hospital understands the importance of asking each patient about their travel history, about their contact history and about their symptoms. And each hospital understands how they need to respond when patients are suspected of diseases like the COVID-19 or MERS or Ebola, how they need to contain it and prevent the disease from spreading in hospitals and to our healthcare workers. And I think one of the things that's also very important was that we have the laws and regulations that was put in place so that, you know, we can get things mobilized very quickly when we do have things like this happen. Over.

Steven Kuo: Yeah. Yeah. The other thing I would like to add if I may is that, after the SARS outbreak, we recruit and add more than thirty medical officers, you know, a really young and talent medical office, like, you know, Angela Wong. I just, we just, heard, her saying about, you know, all of these ideas and actually many of them, we send them to Atlanta US CDC for training two years as EIS officers. So, as I remember, actually, during a period of 10 years, from 2005 to 2015, and at any given times we have medical officers in Atlanta training as an EIS officer but also serve as a liaison for us and connecting Taiwan, CDC, and the US CDC. We another one in Europe serving as the liaison to a European CDC. And so that is all part of our cooperation. You know, we have this extra manpower. So in the case that we have outbreak like this, then we can use. Yeah.

Winnie Yip: William, do you want to continue at all?

WIlliam Hsiao: Well, I don't want to ask too many questions. Again this sounds like really early action. You are able to test the travelers, but how quickly are you able to develop good tests? The DLA sequencing did not occur until January 6th. I'm sorry, the sequencing of the virus did not get announced until January 7th.

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Did Taiwan develop its own testing? Or do you rely on the Germans tests because the United States CDC trying to develop its own tests and it did not work out.

Angela Wang: Right. If I could just attempt to answer this because I'm not a laboratorian. So we actually relied on the WHO protocol. So as soon as the sequence was published, we were able to design that the same sequence so basically that's what most countries were doing. So we looked at the WHO's protocol but we also looked at the protocols that was used in Japan. So, but the protocol that we were using is, or, and we are still using, it's mostly based on the WHO protocol.

William Hsiao: That's the German system.

Steven Kuo: That's the German system. You're right. Yeah.

Winnie Yip: I want to ask a question about what you use the Commander-in-Chief. Now in the US they keep saying that we are lacking a Commander-in-Chief, in our fight against COVID-19. Taiwan, has the Center for Epidemic Controls Center. Can you share with the audience a little bit, what is the function of that center and based on what would trigger to activate it? How is...Who leads it? How does it make decisions? What power does it have in terms of decision making and what decisions need to be approved by others?

Winnie Yip: It's a set of governance questions. And again, this is a question that we have seen in many other countries. Is that one person or one group that actually can make decisions very quickly and based on what, and how is it being activated? So can you share a little bit of that with us?

Jen-Hsiang Chuang: It's a very tough question. We have a Central Epidemic Command Center activated on January 20th. We have three levels for January 20th. We activate the, how do I say, level three Command Center. That's our Taiwan, CDC Director, Director of Taiwan CDC, as a Commander-in-Chief. So in this level, so based on the severity of the disease, then we will change the level to level two, so level two is chaired by our Minister of Health and Welfare and Dr. Chuang, be the Commander and on the level three. Level one, also the Dr. Chuang, but it's how, to say. It's wrong. [inaudible 00:16:43] to give him the, the power to deal the Command Center. So after increase to the level one Command Center, you can see all the course department, they change their step.

Angela Wang: The deputy

Jen-Hsiang Chuang: The deputy minister will become our step of the Command Center, but in level two, only the lower level of the step, come to our command center. So when we increase our level to level one, so we have more The Challenge of COVID 19 The Taiwan Experience (Completed Page 8 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. power on the cross department to make a decision for any major. So for example, to do, to decide, to cross the border, I think it is now from our Commander. It will be from our President, how do you say, her decision. So, so there are a lot of...In later years, and also they also help us a lot to do it. So you can see from the news, our Vice Premier of Dr. Chen Chi-mai. He also helps us to, have the meeting with us and when our minister Dr. Chen Shih-chung to make a decision for any tough question.

Jen-Hsiang Chuang: So, and we also have the everyday press conference, led by Commander, Dr. capture, our commander, Dr. Chen. So his very nice people can explain any question to the public and the journalists. So every people, because his presentation in the conference. So every people liked...commended Dr. Chen recently, because we don't have new local cases. So every county, every Mayor of the county likes to invite him to go to their county, to feel every culture. So currently he is a very good model to transmit the transparency of the information, to the public and to explain every detail of our decision to the reporter and every, every people in Taiwan, very like our Commander. So I think this is my, my, my inspiration.

Winnie Yip: Right? So, so this Command office is headed by the Minister of Health, but with members that are deputy minister from across a number of ministries, including transportation, economy, education, et cetera, that would allow them to make cross sector decisions that are relevant, but also backed up by the executive UN's authority to make decisions.

Winnie Yip: So, Bill, do you have another question? Before I ask another one?

WIlliam Hsiao: Well, I, I think this is on many people's minds that Taiwan is, has been excluded from the WHO because of China's opposition. And do you think being outside the, WHO has hindered your effort to contain, control and manage this virus?

Steven Kuo: Well, I think for this particularly outbreak, I won't say being outside the WHO has had any significant impact on our ability to respond to this outbreak. And because I think in the very beginning, like, you know, year 2000, or the day before 2000, we have been trying to get into the WHO as observers. And, but that was, you know, year 2000. Okay. That was the year that we didn't have many experience. As I indicated, the SARS really served as a wake up call for Taiwan. And we learned a lot and we collaborate with the US CDC and other countries. And so I think the overall disease control system has been improved a lot. And also in year 2009, we are able to join the WHO as an observer. So to some degree we have, we have the experience of being an observer and know, you know, what, you can have to be part of the WHO.

Steve Kuo: And so, you know, things change, I mean, a lot. Okay. So some of the people in Taiwan, including myself say, "Well, it would be wonderful if Taiwan can be part of the WHO" you know, why not, but if we can't is not really a big deal, okay. We still can fight the disease. And, you know, with people, you know, who

The Challenge of COVID 19 The Taiwan Experience (Completed Page 9 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. are friendly to Taiwan. Yeah. I wouldn't say, you know, we are lucky to be not a member of WHo or not an observer. Yeah. But I do know some of my colleagues would argue to say, you know, we are lucky that we are not part of the WHO. So, you know, we work double hard, you know, to try to protect the Taiwan, you know, and also we don't have to listen to what the WHO suggested. I won't say that. I mean, even we are part of the WHO observer, you know, we can make our own decisions, regardless what the WHO says.

Steven Kuo: Yeah. So, you know, so the short answer is no, I don't think it really matters nowadays to be a part of the WHO or not. Yeah. But it would be wonderful if we could be a part of the WHO, but we are not going to bet to be an observer or a member. Yeah. It's only my opinion. Okay. I'm going to say it's not an official government point of view.

Winnie Yip: Yes, it is well noted. Don't worry. So I have another question going back to, I think one of the strategy that Taiwan uses. A broad strategy, Taiwan uses to prevent the COVID-19 to become exponential is your great surveillance, right? Case identification, deploying technology, linking of different databases. Now in the Western society, there's always this question of privacy, confidentiality.

PART 2 OF 4 ENDS [00:52:04]

Winnie Yip: The confidentiality. So has that been an issue in Taiwan and how do you counteract with that?

Angela Wang: It's always the concern with privacy. So I think one of the things, when the outbreak was at its peak here in Taiwan, it's probably middle of March. And the people are interested in the sense that our feelings about things change over time. So when things were tense and when people are panicked, then sometimes these privacy issues don't seem as important. So people were...some people. You're going to see extremes. Some people are happy that these things are happening. So we can all be protected. But of course then there are the few people who have become to be concerned about privacy issues. And as the outbreak is dwindling here in Taiwan, then these--

Winnie Yip: I think we lost Dr. Wang For a little bit.

Steven Kuo: Well, maybe I can continue, or at least try to say. Well, actually privacy issue is an issue, but luckily we had been debating that for a long time, since we have the national health insurance. They collect all the data, issuing the first insurance card I think many, many years ago. And so the privacy issue is over there. So there is a degree of consensus, that you need to strike the right balance, okay? And you need to have a sound security and arrangements for all this information. And so, if I'm correct, actually about two months ago, actually in the Congress, there's a debate and to how to protect the privacy at the same time to use the information. So for contact tracing and that sort of things. And so they come up with a solution that they can collect the information but only with a certain time frame. If I'm correct, is

The Challenge of COVID 19 The Taiwan Experience (Completed Page 10 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. something like the government can keep the information for say 30 days or 40 days, and they have to delete all the information.

Steven Kuo: And that is the way to protect the privacy. So yes, there is a kind of a discussion. And we certainly would argue that the digital technology we are talking here is more a legal issue than a technical issues because a country like the US and other developed country can easily adopt the information and can easily adopt the technology. But you need to take into account the privacy issues. And I think we have been solved that. Yeah, probably not the drunk and answered the question that the Congress has decided we can keep the information for how long is that something that 30 days or 40 days,

Angela Wang: Right? So the Congress has decided that the information could be kept for 28 days. It needs to be erased. So, it definitely is the concern and we are taking into.

Winnie Yip: Bill has any last thing question, maybe we should also give the audience an opportunity to ask questions as well. Steve, do you like us to continue?

William Hsiao: I think we should let the audience have a chance to ask questions.

Steven Goldstein: Well, we'll get to that, Bill. I just want to follow up on this surveillance. Somebody on the Taiwan side a moment ago, talked about the digital fence and that is apparently a very effective and important part of the Taiwan project. And it's probably the most difficult to begin to think about in producing in the United States to be more specific. The digital fence is actually a kind of a tracing of the movements of an individual who is limited to a small space, usually the home. And when they leave that space, they're engaged in what's basically criminal activities.

Steven Goldstein: And the state has the ability to punish them. That would be a tough road if one tried that in the United States. I think so in a sense, what I, as a political scientist, I've gotten to sort of ask myself what is it about Taiwan that makes this possible? Is it a kind of cultural unity or national unity? Is it a legacy of a more authoritarian past? How, why do people accept that?

Jen-Hsiang Chuang: Okay. I think this tall fence system, only a supportive system, but it is not tracking the GPS location of the cell phone owner. It uses only to identify persons whereabouts based on the location of his mobile phone, relative to the nearby cell towers. So which this can reveal the distance of the phone, from a specific cell reception tower. So in our, from our law, we have, we did not allow the people to run out of his home if he has the home quarantine. So the system only a supportive system to base on this law to do it. So if we don't have this system, steps also, we'll call this, this list. Quarantine P person, the two trees per day. And to ask him is he or is any help need to be motif or, and to tell is he out of, so if we

The Challenge of COVID 19 The Taiwan Experience (Completed Page 11 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. don't have [inaudible 01:00:42] this depends [inaudible 01:00:44] this digital pen system, we also, if we know these people did not break our rule, they also need be fine. Right?

Angela Wang: Yes. So I just want to kind of jump in here also. The digital sense system is not as rigid as people think it is. So, if people do leave their area, would they, I mean, the police don't come running over and fine these people and put them in jail. So basically if you leave the premise where you're supposed to be and there is some, that you could go a little distance, because with the triangulation technology it's not that precise. So if people leave their designated area, they actually do get a text message reminding them that they are under home quarantine and they need to go back. And as soon as they go back there's no additional measure that needs to be taken. So, the digital system, fence system is there. You're using triangulation, but there is, we do understand that there are problems with it.

Steven Kuo: Well, perhaps I can answer in this way that actually in 2003, when the SARS outbreak, we quarantine many people. Okay. And there're meetings, I was asked to by a legal counsel from a U S CDC, and he was so surprised that Taiwan can quarantine a person without court order. And actually it struck me, we really don't have to have the court order, but it reminds us that we need to have a legal supporter for us to doing so. So after the SARS outbreak, actually we amended the Communicate Disease Control Act to allow the Commander in Chief to have the power, to issue an order like this, if he's thinks this is the right thing to do. And actually for the COVID outbreak at this time, the Congress passed another law also, giving the authority to the Commander in Chief, we called it a total authority.

Steven Kuo: Perhaps someone were chime in to that, but this is a law debated in the Congress and passed. And so I would say that this issue, perhaps is a cultural one, but we got democratic countries now, like in Taiwan, we do need to have that law to be debated and passed in the Congress. So yes, it's part of the culture, is part of the histories we have because of the SARS outbreak, but also I think it has been done legally and lawfully in Taiwan society right now.

Steven Goldstein: I think we can do that if no one else on the panel has something they would like to, or an issue they would like to raise.

Winnie Yip: So I have one question for both of our Taiwanese friends and for Bill as well. Do you think that, Dr. Wong, makes reference to the fact that Taiwan has a single payer system and therefore care is affordable and you have a comprehensive database? So do you think that COVID-19 would be, maybe this is for Bill you asked to move towards more of a single payer system?

William Hsiao: Wow.

Winnie Yip: You can limit yourself to...30 second answer. The Challenge of COVID 19 The Taiwan Experience (Completed Page 12 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here.

William Hsiao: I will say I don't have that ability to read the tea leaves. I think United States right now is in turmoil in flames and I don't know how the politics here in United States and the people actually going to be reacting. But I hope personally this Covid as well, the death of George Floyd produced such a huge earthquake, United States will wake up and reform with political and the social and economic system. United States has grown in my opinion, to be an equal and just society. It's not an exemplary nation for democratic form of government.

Winnie Yip: Maybe we should turn to the audience QA. And I would just say that I look forward to the date when Taiwan open up the borders so we can travel that again. And when might that be?

Jen-Hsiang Chuang: Okay. It's we currently, we are enjoying our domestic traveling because currently we don't have any case locally. When we lift our border because we need to, currently, we are trying to categorize the race of the nation or into four categories. Based on the incidence of the cases, the transparencies of and test taking capacity and mutual trust that's one, the mutual trust. So, because we need to have some that they are in with, with the country to have such kind of traveling, mutual travel bubble such kind of idea. So it needs to have some negotiation. So we need our staff to go to tell with such kind of information with other country. I think we still at least one month later to tell with such kind of information. Yeah.

Winnie Yip: Right. Let's turn over to Steve.

Steven Goldstein: Yeah. Sure. Thanks Bonnie. One reflection on what Bill said as I was listening to him, I was thinking that actually the Taiwan experience might be used as an argument against single-payer national health. I can see people in this country arguing that it'll just make the government even more intrusive, give the government even more information. And when you've got a population that's talking about their right, not to wear a mask, the idea that there would be a central compilation of the population, I think is difficult to see being sold. And I think it may, in fact, they use as an argument against a single payer, which is unfortunate.

Steven Goldstein: There are two populations in Taiwan that we haven't talked much about. One is the elderly population, particularly old age homes. It seems that's a center of COVID-19 in the United States. And I was wondering how Taiwan is handling that, old people under care. The second thing of course is the [foreign language 00:18:33] the Aboriginal population. I haven't heard much about them or read really read much about them, or are they fully integrated into this program or the system as well?

Angela Wang: So we. Yes, go ahead.

Steven Kuo:

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Well, in terms of the elderly, I think in the very beginning, so we know that they will be the most vulnerable ones, like my mom, she lives, well actually, most of the time it with me, but is 85. And so she's the most vulnerable one. So people are knowing that we need to protect the elderly either they live in their home or they're with their kids. And so, as a matter of fact, my mom stayed home even without an order of stay at home. She stayed at home for almost two months already. Yeah. And also for the longterm care facility, I know the government has special programs to try to protect them, to ban the visiting of the visitors and that sort of thing.

Steven Kuo: So there're programs on the longterm care. I don't know too much about the Aboriginal people, but I don't think that would be a kind of a problem. But because now you say we didn't reach the point of out of control. So most of the people in Taiwan are still pretty lucky it has been taken care of well. But I, because the national health insurance cover 99% people, including the elderly, including the Aboriginal. So they have been treated equally. And so I don't really think that would be a particular problem for those two people, maybe Dr. Jong or Andrew can add on that. Yeah. Dr.

Angela Wang: Yes. Hi, sorry. One of the first things that we actually did to ask people, not to go visit their elderly, and it's very, very difficult. So, visitors to the longterm care facilities were limited. That prevents people from bringing diseases into these care facilities. And then a lot of the other elderlies that either are living with their families and or have other carers at home and because everyone is wearing mask, whether they want to or not. And just like what Dr. Gould has said, our elderlies also were very worries about being infected. So they were also staying home and avoiding a lot of places that they would usually leave the other elderly people. Our Aboriginal population hasn't really been affected disproportionately. This really is a disease that are imported so we have not seen the disease being spread in our Aboriginal population.

Steven Goldstein: Well, we have a question from one of our listeners or one of our participants. The question is the applicability of what's been done in Taiwan to a larger context that has the scale of Taiwan, not the culture, which we've been talking about earlier, but the size, has the size of Taiwan made a difference in responding to the COVID-19 virus. And if that's the case, how applicable are or one of the more applicable lessons that can be used elsewhere, and what are the less applicable lessons that can be used elsewhere?

Steven Kuo: Well, it seems to me the size, probably not the size of being an island has to do was our ability to control. So like the New Zealand, they have been doing that so well with the very enhanced border control. New Zealand have 4.5 millions of populations and Taiwan has 23 millions in a well, relatively small Island, I would say. So I'm not quite sure the size of the populations. I would probably argue that in a country with 23 million people it is not a small size of countries. Yeah. And so, I think was, as you know, that we did, we shut down the borders very early on, and that certainly allowed us to stop the virus keep importing to Taiwan. And that, I think that's the key probably less to do with the size of the Island or the population.

Steven Goldstein: The Challenge of COVID 19 The Taiwan Experience (Completed Page 14 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here.

Interesting. Anyone else on the panel have I...have other questions that I can ask. All right. The issue of a second wave. One of the questions that's come in is about the possibility of a second wave, which is certainly an item being discussed in the United States. What preparations will you be making for a second wave? And if Taiwan's primary advantage or one of Taiwan's most important ways of responding to the COVID virus was to in a sense close down the Island?

PART 3 OF 4 ENDS [01:18:04]

Steven Goldstein: Just down the island to people coming in. Then the second question is, if there is going to be a second wave, can one think about traveling to Taiwan in the future? Or will that be unlikely?

Jen-Hsiang Chuang: Okay. Currently we are trying to promote our people or new normal to prevent the future [inaudible 01:18:47]. So we promote the people who have the social distancing. If they cannot maintain the social distancing they must wear face masks. In the future, we open the border and we want face masks to protect our people. Now, if there is any infectious case entering to Taiwan then we have such kind of personnel to stop the train station this hour, the first people of protection. Then we also try to investigate the best nation from our domestic manufacturer vaccine manufacturer.

Jen-Hsiang Chuang: And also trying to investigate other vaccine manufacturer in the other country. If any chance we can get another vaccine in future, so this is the current ... our strategy.

Steven Kuo: I think certainly we are worried about the second wave or the third wave or fourth wave. Actually in Taiwan, we call the first wave as the wave from the men in China, and the second wave is from the European and the US. And so now if we open up the portal then there's probably another wave and surely even the virus disappears for the summer times, as you say, it probably coming back in the winters. So as long as we are try to open up the border, then we have a higher risk to get the virus come in. And that's why, as Dr. Chuang saying the commander-in-chief is really struggling to make the right decisions to when and how to open the borders. And he is suggesting that they are starting to open up slowly, perhaps for a country like New Zealand or Vietnam, or . I don't know, I can not say for the government, but I think they are discussing that.

Steven Kuo: Also, certainly we have not seen preparedness and production is another big issue. As I understand the government is trying to secure the supply of our vaccines given the fact that we do have more than two vaccine manufacturers here in Taiwan. One of them are collaborating with a US NIH to have a vaccine for a long time. They have a collaborations for about five years since the dengue vaccine. So, yes, it's a concern and like Professor Hsiao say, you have to prepare in advance and so we are doing the same.

Steven Goldstein: We have a question from a Taiwan citizen in and that citizen asks, "If the WTO was not that helpful why does Taiwan want to become a part of it?"

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Steven Kuo: Well, actually that's what I'm trying to say, right? Let me put it this way. Actually, is currently in Taiwan, there's three group of people. Okay? With regard to WHO, one group of people is arguing that we should be a full member instead of a observer. That's the first group of people. The second group of people, probably the majority of people, they want to be an observer but was respect and dignity, and also without anyone invitations. That is another group of people. And the third group of people is probably a minority, but that includes me and others, my friends, that say, "You know, we really don't have to be part of the WHO, okay?" This is not a organization that we want to be.

Steven Kuo: So the answer is that there are people want to be part of the WHO but also there are people like me, we don't really care about the WHO anymore. And so it really depends and since the US is ... well, it's not really US, it's President Trump trying to withdraw from WHO. Then there another reasons probably Taiwan cannot or shouldn't reconsiders our positions. By the way, my deputy president is a former AIT director called Bill Stanton who probably you heard about. He is now my deputy at National Yang Ming University and he is one of the people arguing that power needs not to be WHO. And there's USA. So people probably have different views. I would say the attitude is changing rapidly.

Steven Goldstein: Winnie, did you have a question?

Winnie Yip: I was just wondering if we can have our friends from Taiwan catch on a little bit? You don't suffer from major economic shutdown, shutting down school et cetera. But with the tight border control, how has that affected the economy? Is that one consideration in terms of thinking about opening up?

Steven Kuo: Well, like Dr. Chuang said earlier, we are seriously considering opening up the borders and open up the economy. For the domestic economy, actually we never shut it down. So it's probably say 90% opened up. And people are scared to go to the restaurant, that's for sure, but for most of the activities is relatively normal. But you are absolutely right. We need to open up the borders sooner or laters.

Steven Kuo: I would argue that actually in Taiwan we are probably a little bit to obsess with zero cases, especially when you are talking about all the asymptomatic cases. So the cases we know is the cases that we detect. There are probably cases that we didn't detect, although I don't think there are many undetected cases. What I'm trying to argue is that we should open it up. Maybe there is new cases, even local transmissions, but given the fact that Taiwan has the ability to control it, why not we just open it up? Tried it? And since we have a very good and robust surveillance system, we can detect it right early on and then we stamp it. It probably ... after you open the border there's a kind of a blitz all the way but it's not going to hurt.

Steven Kuo:

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And that is the way to go, I would argue, but the government probably have their thinking. But basically we are at a time that it's about time to open it up or at least to try to open it up. And I just heard a Dr. Goldstein say there's a audience from Beijing, right?

Steven Goldstein: Yeah.

Steven Kuo: And actually many of my students is now in Beijing and couldn't come home ... come to Yang Ming for the graduation commencements. And we have been in teleconference many times and I wish we can get them back to Taiwan to continue their educations, but still is under discussion. It's not being resolved. We are pretty much like, you know, to open up at the border and have them to come back. But I'm pretty sure that we are in good hands, Dr. Chuang and the commander-in-chief will make the decision, the right decision, pretty soon.

Steven Goldstein: You've used the term commander-in-chief a number of times. Could you just define whom you're talking about?

Steven Kuo: Okay. Well, actually this is the question that Winnie just asked about, the governance. That's ... we learned in SAS outbreak. So I keep saying that SARS is the wake-up call for Taiwan. We learned a lot, and that is one of them. During the SARS outbreak, we had that fight between the central government and the local governments, and we don't know who should make the final decision. After the SARS outbreak, and actually during the SARS outbreak, we come up with this idea that we need to have someone that really have the power to make the command. At that time, the president Chen ask a former health minister, Professor Lee, that Bill know very well, to be the commander-in-chief. And so later on, we kind of legalized the terms and put it in our law and say once you have an outbreak like this then the government can activate a commander in the Central Epidemic Control Center, and then appoint a person to be the commander-in-chief.

Steven Kuo: So just like Dr. Chuang just mentioned, if is in the early phase of the outbreak then you ask the director of Taiwan CDC to serve as the commander-in-chief. If the epidemic escalate, then you will ask the house minister to be the commander-in-chief. If it escalate again, then you will ask the premium or the vice premium to serve as the commander-in-chief. Once you use the term commander-in-chief, you switch into a commanding mode, like fighting a war.

Steven Kuo: So that is a way of communications. That's the way of telling the public that we are in a different mode. He is no longer health minister or director of Taiwan CDC. Now he has embraced a bigger power and we are fighting the disease. So it's a matter of communications.

Steven Goldstein:

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We have another question from a participant. How will the United States' apparent withdrawal from the WHO affect Taiwan? Has that been a source of information for Taiwan in the past? ... In other words, the United States is talking about withdrawing, or the president talking about withdrawing, from the WHO. Will that affect the information flow to Taiwan, which we assume has indirectly come through Washington to Taiwan? Or from the CDC in this country to Taiwan?

Steven Kuo: Well, I don't think so. Other than the United States, we still have 20 something allies who has been in the WHO as well. If we are talking about getting information through US, then it won't be changed because we can still get the information from other allies. I don't think that is a big difference. But it will make a case for Taiwan that since even US doesn't want to be a part of WHO then the argument that people say, "Why we should be a part of the WHO," will probably grow louders. We will sort of stick with the US and we probably can have our own organizations like some other people argue. I think if the US withdraw from WHO then there were more people arguing for not to be with WHO anymore. And that's probably is going to happen.

Steven Goldstein: Any members of the panel have anything that they would like to add to that?

Winnie Yip: I just want to convey a message from Michael Szonyi, the Director of Fairbank Center, that he wants to express his welcome but also appreciation for our Taiwanese speakers sharing the experience with us.

WIlliam Hsiao: I want to say, whether Taiwan become a member or observing WHO, needs to be looked at in larger context. Whether Taiwan is recognized in the world, international organizations and the WHO membership give Taiwan's most legitimate reason to say "I am part of the world." And with the infectious diseases, viruses that do not respect national boundaries, every country should be in it. And I think that that's the argument. Not necessarily Taiwan would receive that much direct health benefit, because actually WHO information and standards set by WHO, and the information generated by WHO, that's made public immediately. There's no ... and Taiwan being a member or not member doesn't really get that much benefit.

WIlliam Hsiao: So it's a larger question rather than a simple, a health question, whether Taiwan wants to or should be in WHO.

Steven Kuo: In a sense, it's probably more a political issues than just a health issues, I would say.

Steven Goldstein: I think that's the way it seems to me as well. That it is all part of Taiwan's wish to increase its international profile. And what I found very interesting about our discussion today is the fact that in terms of control of the disease and Taiwan's response, the WHO is ... it's not considered to be that important. And in fact, some of our participants have speculated that non-membership in the WTO was The Challenge of COVID 19 The Taiwan Experience (Completed Page 18 of 19 06/30/20) Transcript by Rev.com This transcript was exported on Jul 02, 2020 - view latest version here. actually an advantage. And that's one of those chance occurrences that happen in history and make a difference.

Steven Goldstein: We're coming to the end and I can't resist, as a person who taught at a women's college, Smith college, for a very long time, to note another happened chance. And that is that Taiwan has a female president. Some of the most successful countries in the world I have been told over and over again, have female presidents. Germany, England, New Zealand, Iceland, Denmark. So perhaps we should include that as a factor as well. No, it isn't very scientific, I admit. Anyway, I do want to thank our panel ... did you want to say something Dr. Chuang?

Jen-Hsiang Chuang: Thanks. It's my pleasure to go in these online presentations and it's very interesting and nice to [inaudible 01:40:14] thank you [inaudible 00:22:21].

Winnie Yip: Thank you for having me.

Steven Goldstein: Well, thank you to all of you. We've just been listeners. You've been doing the work. Thanks to Winnie. Thanks to Bill. Thanks to the people on Taiwan and thanks to the participants. I'm sorry we couldn't use all the questions that we got but I think it was a very useful session and we appreciate everybody's efforts. Also, I should mention Mark Grady at the Fairbank Center who was able to put together this technological miracle. So thank you all.

PART 4 OF 4 ENDS [01:41:08]

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