By Ko Shu-ling,
Based on its proximity to China and extensive cross-strait travel, Taiwan was initially ranked among locations most likely to be overrun by the new coronavirus when it appeared last December.
Seven months later, however, with COVID-19 infecting millions, Taiwan Centers for Disease Control reports seven deaths to date, 28 active cases and no domestic transmissions since April.
This was achieved without support from the World Health Organization, which at China's insistence excludes Taiwan, and without a general lockdown, thereby allowing most residents to go about their lives as usual.
Reasons given for Taiwan's pandemic success include quick government action, widespread support for TCDC directives, and a medical system ranked the world's best on the Numbeo Health Care Index.
Yet, to understand how a diplomatically isolated travel hub of 23 million people neutralized a threat that has decimated health care systems in many wealthy nations requires more than a list of things Taiwan did right in the current crisis.
Even crediting the changes to Taiwan's health care administration following the 2003 SARS epidemic omits a history of dealing with problems like COVID-19 that dates from the colonial period.
According to Lin Man-houng of the Academia Sinica's Modern History Institute, Taiwan's health care system originated in Japanese efforts to contain infectious diseases like malaria, cholera, dysentery, typhoid and bubonic plague that proliferated on the island due to its subtropical climate and ignorance concerning how conditions might be improved.
Taiwan was known as "the land of miasmal diseases," and given the human cost of settlement, Qing Dynasty rulers pursued minimal development.
Even defending the island proved difficult.
Thousands of Chinese troops died, not in fighting, but from infection after being sent to Taiwan in 1874 following the Mudan Incident, with Japanese invaders faring no better.
Returning 20 years later, after China ceded Japan the island following the First Sino-Japanese War, Taiwan's new rulers seemed to have learned little from their earlier experience, as the initial occupation force logged 164 casualties in fighting and 4,624 from what they called "Taiwan fever."
Among the dead was Prince Kitashirakawa Yoshihisa, the campaign's leader and a member of Japan's royal family.
Planners were not totally unprepared, however, and while infection persisted, Shimpei Goto, head of the new government's Civil Affairs Bureau, placed disease at the top of his list of problems to tackle in stabilizing Japanese rule.
And by that time, Goto was not without resources.
Following the Meiji Restoration, Japanese authorities sent students to study in Europe, where significant progress was being made in the prevention and treatment of infectious diseases.
They also invited Western experts to advise and teach in Japan.
In 1896, Scottish sanitary engineer William Burton arrived in Taiwan to oversee the construction of sewers and a modern water treatment plant in Taipei, the new colony's capital, leading to dozens of similar projects across the island and causing a steady decline in cholera.
Malaria and the plague were also targeted. Both having recently been identified as spread by mosquitos and rat-born fleas, Tomoe Takagi, head of the Health Department, developed programs to rodent-proof island ports and drain mosquito-infested wetlands.
Hygiene laws also required intensive house cleaning and compulsory blood tests, with those found infected subject to quarantine.
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Yet according to Fan Yen-chiou, Professor of History at National Taiwan Normal University, Takagi's most effective innovations were not sanitary but social.
Taiwanese traditionally turned to folk religion to protect them from disease, and they resisted measures stipulated under the "Major Cleaning Law," which included not only testing and isolation but also burning personal belongings to eliminate infection.
To counter resistance, officials moved slowly and solicited help from trusted members of the community, such as local gentry and Chinese medicine doctors.
The program was so successful that housecleaning became a task Taiwanese families carried out before every Lunar New Year.
What Fan calls a "collaboration between new and old" extended beyond disease prevention to treatment, with authorities allowing traditional doctors to continue practicing, even while expanding access to Western medicine.
This expansion relied on medical personnel trained in Europe or Japan, at schools like the Institute for Study of Infectious Diseases, founded by Shibasaburo Kitasato, who studied under renowned German microbiologist Robert Koch, after which he played a leading role in the fight against diphtheria, dysentery and the plague.
Taiwan's first modern hospital was a military field station in Taipei's Dadaocheng area, which was later relocated to the city center and eventually became the outpatient department of National Taiwan University Hospital.
The colonial government went on to build hospitals and medical schools throughout Taiwan, with special facilities dedicated to treating diseases like pneumonia and leprosy, as well as clinics in rural areas to provide vaccinations, health education and other basic services.
Private hospitals also became ubiquitous, with 350 island-wide by 1942 employing 1,660 doctors.
It would take over 20 years to bring Taiwan's "miasmal diseases" under control, a remarkable achievement for which the government was rewarded with not only improvements in general health and life expectancy, which increased 50 percent in 30 years, but, as Goto predicted, a more stable colony.
Japan withdrew from Taiwan in 1945, leaving a health care system that the Nationalist (KMT) government would continue to build on, with infectious diseases still one of its greatest challenges.
It would be 1965 before the WHO declared malaria finally eradicated on the island.
Authorities also borrowed from other countries, developing what Chen Hsiu-hsi, associate dean of NTU's College of Public Health, calls a "hybrid model" of health care that "makes it easier to integrate medical care and public health."
Changes have included a more generalized education for physicians, so that they can operate in a wider range of capacities, and the creation of the TCDC as a semiautonomous government agency to highlight the importance of separating politics from the fight against diseases.
In 1995, Taiwan's government also implemented a National Health Insurance plan to provide comprehensive medical services to all residents.
In a nod to the wisdom of Takagi's "collaboration between new and old," even today, with a new epidemic raging, the NHI covers those who prefer Chinese over Western medicine.
