Taiwan is only 81 miles off the coast of mainland China and was expected to be hard hit by the coronavirus, due to its proximity and the number of flights between the island nation and its massive neighbor to the west.

Yet it has so far managed to prevent the coronavirus from heavily impacting its 23 million citizens, despite hundreds of thousands of them working and residing in China.

According to the Johns Hopkins Coronavirus COVID-19 Global Cases map, as of Tuesday there were only 42 cases and one death in Taiwan, far behind China, with more than 80,000 cases and more than 2,900 deaths. The country also lags far behind its other Asian neighbors and ranks 17^th in the world for the number of global cases. As of this writing, South Korea was second, with 5,186 cases; followed by Iran with 2,336 and Italy with 2,036 people infected with the virus.

The United States currently stands at 107 known cases and six deaths.

The viral outbreak in China occurred just before the Lunar New Year, during which time millions of Chinese and Taiwanese were expected to travel for the holidays.

So what steps did Taiwan take to protect its people? And could those steps be replicated here at home?

Stanford Health Policy’s Jason Wang, MD, PhD, an associate professor of pediatrics at Stanford Medicine who also has a PhD in policy analysis, credits his native Taiwan with using new technology and a robust pandemic prevention plan put into place at the 2003 SARS outbreak.

“The Taiwan government established the National Health Command Center (NHCC) after SARS and it’s become part of a disaster management center that focuses on large-outbreak responses and acts as the operational command point for direct communications,” said Wang, a pediatrician and the director of the Center for Policy, Outcomes, and Prevention at Stanford. The NHCC also established the Central Epidemic Command Center, which was activated in early January.

“And Taiwan rapidly produced and implemented a list of at least 124 action items in the past five weeks to protect public health,” Wang said. “The policies and actions go beyond border control because they recognized that that wasn’t enough.”

Wang outlines the measures Taiwan took in the last six weeks in an article published Tuesday in the Journal of the American Medical Association.

“Given the continual spread of COVID-19 around the world, understanding the action items that were implemented quickly in Taiwan, and the effectiveness of these actions in preventing a large-scale epidemic, may be instructive for other countries,” Wang and his co-authors wrote.

Within the last five weeks, Wang said, the Taiwan epidemic command center rapidly implemented those 124 action items, including border control from the air and sea, case identification using new data and technology, quarantine of suspicious cases, educating the public while fighting misinformation, negotiating with other countries — and formulating policies for schools and businesses to follow.

Big Data Analytics

The authors note that Taiwan integrated its national health insurance database with its immigration and customs database to begin the creation of big data for analytics. That allowed them case identification by generating real-time alerts during a clinical visit based on travel history and clinical symptoms.

Taipei also used Quick Response (QR) code scanning and online reporting of travel history and health symptoms to classify travelers’ infectious risks based on flight origin and travel history in the last 14 days. People who had not traveled to high-risk areas were sent a health declaration border pass via SMS for faster immigration clearance; those who had traveled to high-risk areas were quarantined at home and tracked through their mobile phones to ensure that they stayed home during the incubation period.

The country also instituted a toll-free hotline for citizens to report suspicious symptoms in themselves or others. As the disease progressed, the government called on major cities to establish their own hotlines so that the main hotline would not become jammed.

Some might say that because Taiwan is such a small country — about 19 times smaller than Texas — it is easier to mobilize during emergencies. Yet Taiwan is particularly challenged by its proximity to China and the fact that 850,000 of its citizens reside on the mainland; another 400,000 work there. Taiwan had 2.71 million visitors from China last year.

So when the WHO was notified on Dec. 31, 2019, of a pneumonia of unknown cause in Wuhan, China, Taiwanese officials began to board planes and assess passengers on direct flights from Wuhan for fever and pneumonia symptoms before passengers could deplane.

As early as Jan. 5, notification was expanded to include any individual who had traveled to Wuhan in the past 14 days and had a fever or symptoms of upper respiratory tract infection at the point of entry. Suspected cases were screened for 26 viruses, including SARS and MERS. Passengers displaying symptoms were quarantined at home and assessed whether medical attention at a hospital was necessary.

What the U.S. Could Learn

One of Wang’s co-authors, Robert H. Brook, M.D., ScD., of the David Geffen School of Medicine at the University of California, Los Angeles, said Washington could learn a great deal from Taiwan’s so-far successful management of the virus.

“In Taiwan, diverse political parties were willing to work together to produce an immediate response to the danger,” said Brook, also of the nonprofit RAND Corporation. “Transparency was critical and frequent communication to the public from a trusted official was paramount to reducing public panic.”

The other co-author of their study is Chun Y. Ng, MBA, MPH, of The New School for Leadership in Health Care, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.

Brook said Taiwan got out ahead of the epidemic by setting up a physical command center to facilitate rapid communications. The command center set the price of masks and used government funds and military personnel to increase mask production. By Jan. 20, the Taiwan CDC announced that it had a stockpile of 44 million surgical masks, 1.9 million N95 masks and 1,100 negative pressure isolation rooms.

“In a country as complex as the United States,” Brook said, “there needs to be a sharing of intelligence on a real-time basis among states and the federal government so that action is not delayed by going through formal channels.”

Please contact Beth Duff-Brown for media requests. 

U.S. government aid for treating children and adults with HIV and malaria in developing countries has done more than expand access to lifesaving interventions: It has changed how people around the world view the United States, according to a new study by researchers at the School of Medicine.

Compared with other types of foreign aid, investing in health is uniquely associated with a better opinion of the United States, improving its “soft power” and standing in the world, the study said.  

Favorability ratings of the United States increased in proportion to health aid from 2002 to 2016 and rose sharply after the implementation of the President’s Emergency Plan for AIDS Relief in 2003 and the launch of the President’s Malaria Initiative in 2005, the researchers report.

Their findings were published this week in the American Journal of Public Health. The lead author is postdoctoral scholar Aleksandra Jakubowski, PhD, MPH. The senior author is Eran Bendavid, MD, associate professor of medicine and a core faculty member at Stanford Health Policy.

“Using data on aid and opinions of the United States, we found that investments in health offer a unique opportunity to promote the perceptions of the United States abroad, in addition to disease burden relief,” the authors wrote. “Our study provides new evidence to support the notion that health diplomacy is a net win for the United States and recipient countries alike.”

The Trump administration, however, has proposed a 23% cut in foreign aid in its 2020 budget, including large reductions to programs that fight AIDS and malaria overseas.

The Stanford researchers believe their study is the first to add heft to the argument that U.S. health aid boosts the “soft power” that wins the hearts and minds of foreign friends and foes.

“Our study shows that investing in health aid improves our nation’s standing abroad, which could have important downstream diplomatic benefits to the United States,” Jakubowskisaid. “Investments in health aid help the United States accumulate soft power. Allowing the U.S. reputation to falter would be contrary to our own interests.” 

A Policy Debate

Many politicians and economists consider spending U.S. tax dollars on foreign aid as an ineffective, and possibly harmful, enterprise that goes unappreciated and leads to accusations of American meddling in other countries’ national affairs.

The U.S. government, for the past 15 years, has contributed more foreign health aid than any other country, significantly reducing disease burden, increasing life expectancy and improving employment in recipient countries, the authors wrote. Still, this generosity has historically constituted less than 1% of the U.S. gross domestic product.

“Our results suggest that the dollars invested in health aid offer good value for money,” the researchers wrote. “That is, the relatively low investment in health aid (in terms of GDP) has provided the United States with large returns in the form of improved public perceptions, which may advance the U.S. government’s ability to negotiate international policies that are aligned with American priorities and preferences.”

The researchers used 258 Global Attitudes Surveys, based on interviews with more than 260,000 respondents, conducted by the Pew Research Center in 45 low- to middle-income countries between 2002 and 2016.

Their analysis focused on the health sector, which includes several large programs for infectious disease control, but also support for nutrition, child health and reproductive health programs. They compared health aid to other major areas of U.S. investment: governance, infrastructure, humanitarian aid and military aid. They also constructed a database of news stories that mentioned the President’s Emergency Plan for AIDS Relief or the President’s Malaria Initiative by crawling through the online archives of the top three newspapers by circulation in each of the 45 countries.

They found that the probability of populations holding a very favorable opinion of the United States was 19 percentage points higher in the countries where and years when U.S. donations for health care were highest, compared with countries where and years when health aid donations were lowest. Using another metric, the researchers found that every additional $100 million in health aid was associated with a nearly 6 percentage-point increase in the probability of respondents indicating they had a “very favorable” opinion of the United States. 

In contrast, the researchers found, aid for governance, infrastructure, humanitarian and military purposes was not associated with a better opinion of the United States.

Bendavid, an infectious diseases physician and core faculty member of Stanford Health Policy, said that when he set out to conduct this research, he believed it would result “in a resounding thud” — that the “soft power” of health aid would have no impact on public opinion.

“For me, the notion that this program — hatched and headquartered in D.C. — would have impacts among millions in Nairobi and Dakar, seemed farfetched,” Bendavid said. “I was incredulous until all the pieces were in place.”

The ‘America First’ Agenda

The Trump administration’s “America First” agenda is calling for significant cuts to global health aid, particularly to the highly successful AIDS relief program, which was established by President George W. Bush. The administration’s budget, released in March, proposed a $860 million cut to the program; the President’s Malaria Initiative is facing a $331 million reduction in federal funding. That’s a decline of 18% and 44%, respectively.

The U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria would also decline by 17%, or $225 million, according to the Kaiser Family Foundation.

Yet beyond the reputational damage to the United States, such cuts could be a major setback to improving health outcomes in developing countries, the researchers said. After all, HIV knows no borders, and having more resilient health care systems is instrumental when facing public health crises, such as the Ebola outbreak in the Democratic Republic of Congo, Jakubowski said.

“The most direct impact of cutting the United States’ health aid allocations is the potential to undermine or reverse the progress that has been enabled by U.S. aid in curbing mortality and the spread of disease,” Bendavid said. “However, this study suggests there are also repercussions to the United States: the relationships the U.S. has built with recipient nations could also be undermined.”            

Other Stanford co-authors are Steven Asch, MD, MPH, professor of medicine, and former graduate student Don Mai.

Stanford’s Department of Medicine supported the work.

The Ebola epidemic, which could affect hundreds of thousands of West Africans, can only be contained by rebuilding public trust and local health systems decimated by years of neglect, according to a panel convened by the Freeman Spogli Institute for International Studies and Stanford Medicine. FSI Senior Fellows David Relman, Paul Wise, Stephen Stedman, Michele Barry and Douglas Owens were among the panelists.

The World Health Organization estimates 2,811 people have died of the virus since the outbreak began earlier this year and that 5,864 people currently are infected in Sierra Leone, Liberia, Guinea, Senegal and Nigeria.

In this Stanford Medicine news story, Owens, a professor of medicine and director of the Center for Health Policy at FSI, cites a new report by the Centers for Disease Control and Prevention that estimates that even with "very aggressive" intervention, there would be at least 25,000 cases by late December. If intervention is delayed by just one month, the CDC estimates there would be 3,000 new cases every day; if it's delayed by two months, there will be 10,000 new cases daily. "It gives you a sense of the extraordinary urgency in terms of time," Owens told the audience.

Relman and CISAC biosecurity fellow Megan Palmer have also done a Q&A about the virus.

And you can listen to a KQED Public Radio talk show about Ebola that included Relman. 

Dr. David Relman investigates the secrets of the life sciences to help build a safer world.

The Stanford microbiologist and professor of infectious diseases has been named the next co-director of the university’s Center for International Security and Cooperation (CISAC). An adviser to the federal government on emerging biological threats, Relman believes his new role at CISAC will strengthen its core mission of making the world a safer place.

“There is a strong link between microbiology, infectious diseases and international security,” Relman said. “It is increasingly clear that the destabilizing effects of human population growth and displacement, environmental degradation and climate change are all mediated in part through the emergence and spread of infectious diseases. In addition, rapidly evolving capabilities of individuals in the life sciences around the globe make it increasingly likely that this science will be used to cause harm.”

Relman, the Thomas C. and Joan M. Merigan Professor at Stanford and chief of infectious diseases at the VA Palo Alto Healthcare System, has advised the U.S. government about pathogen diversity, biosecurity and the future of the life sciences landscape. He is a member of the National Science Advisory Board for Biosecurity (NSABB), chairs the Forum on Microbial Threats at the Institute of Medicine in Washington, D.C. and has participated in a number of studies for the National Academies of Science.

"David Relman is one of the nation’s top scientists exploring the mysteries of infectious disease, a thoughtful adviser to policymakers, and an extraordinary colleague,” said Tino Cuéllar, a Stanford Law School professor and the center’s co-director. “He will make tremendous contributions to CISAC's leadership as we expand our activities on public health and biosecurity while continuing our work on arms control and nuclear security."

Founded nearly three decades ago, CISAC’s mission is to produce cutting-edge research and spread knowledge to build a safer world. Now a part of the Freeman Spogli Institute for International Studies (FSI), the center has a tradition of appointing co-directors – one from the social sciences and the other from the natural sciences – to advance the center’s interdisciplinary mission.

Relman will take up the post in January, when Siegfried Hecker’s term concludes after having served as co-director since 2007. Hecker, a nuclear scientist and director emeritus of the Los Alamos National Laboratory, is one of the world’s foremost experts on plutonium, nuclear weapons and nonproliferation. He will remain at CISAC and continue to teach in the department of Management Science and Engineering.

“It has been a personal pleasure to work with Sig,” said Cuéllar. “He has been an enormous asset to CISAC.  He will continue to be a visionary leader on nuclear security and arms control issues throughout the world.”

Relman joined Paul Keim, acting chair of the NSABB, to address a CISAC seminar in March about their work in advising the government on the potential dangers of laboratory-engineered H5N1 avian influenza.

The advisory board had been asked to review two manuscripts that described the deliberate modification of the H5N1 avian influenza virus so as to be transmissible for the first time from mammal to mammal via a respiratory route. This provoked a debate in the scientific community about the risks of such work and whether the details of these experiments should be published – details that would enable anyone skilled in the art of virology and molecular biology to recreate these highly virulent and transmissible viruses. Some argued that the research could end up in the wrong hands. The board eventually recommended in a split decision that this research should be published.

“Life scientists need to be involved in discussions about the oversight of risky science and the responsible conduct of science, so that the potential benefits can be realized while the risks are minimized,” Relman said.

Relman will continue to run his research lab at the Stanford University School of Medicine and the VA Hospital in Palo Alto, where his focus is on the beneficial communities of microbes in the human body. He is president-elect of the Infectious Diseases Society of America and a member of the Institute of Medicine at the National Academies of Science. He received his S.B. in biology from MIT in 1977 and an M.D. from Harvard Medical School in 1982. He completed his clinical training in internal medicine and infectious diseases at Massachusetts General Hospital in Boston.

“The appointment of a life scientist who focuses on infectious diseases and biosecurity is an innovative step for our work in international security and cooperation,” said Gerhard Casper, president emeritus of Stanford University and director of the Freeman Spogli Institute for International Studies.

Relman tells a story that illustrates his passion for scientific discovery. On a routine visit to his dentist about 15 years ago, he brought along his own test tube. He asked the dentist to give him some plaque that he had scraped off Relman’s teeth. He wanted to study his own bacteria.

“As a clinician, I can tell you my colleagues were not looking for new microbes to worry about,” Relman said. “Some of them believed there might well be some really weird new microbes in soil or in the ocean, but that the human microbial ecosystem was something that we understood quite well. Of course – that was wrong.”

Using DNA sequencing technology, he has since discovered hundreds of new bacteria in the human body.

“Our ability to predict the next important technical or conceptual advance in the life sciences is miserable, as is our ability to anticipate how these advances will be used,” Relman said. “But we can at least hope to engage the scientific community and the general public in discussions about our goals and our understanding of risks – and how best to mitigate them.”