Dr Tzay-Jinn Chen, M.D., MPH, Deputy Minister of Department of Health (DOH) in Taiwan, graduated as a medical doctor from College of Medicine, National Taiwan University and obtained a Master Degree in Public Health from Harvard University, USA.
Dr Chen has served as Superintendent of Taipei City Chronic Disease Hospital and Taipei City Ho-Ping General Hospital, Specialist General and Chairman of the Hospital Management Commis-sion in the DOH, Director-General of the Bureau of Health Promotion & Protection, as well as for the Center for Disease Control under DOH.
His professional specialties include chest and critical medicine, nephrology, internal medicine, occupational medicine, hospital management and quality control, health promotion and infectious disease control.
You are known for being one of the central people in the fight against SARS. Could you tell us a little of what happened during those months in the fight against SARS? And how did you manage both at a personal level and at the public level, to face the whole pressure of public opinion in Taiwan?
In the spring of year 2003, Taiwan, along with 32 other countries and other areas around the globe, was struck by the SARS epidemic, which caused 73 deaths out of 346 known infected cases in Taiwan. As soon as the illness of a Taiwanese businessman was diagnosed as the first SARS case after his return back from China, the Taiwan Center for Disease Control (CDC) undertook a number of tight measures to prevent the spread of the epidemic in Taiwan. But, later arrived a resident of Hong Kong’s Amoy Gardens Complex – the most severely affected area in Hong Kong; he had come to Taiwan to sweep relatives’ graves and had accidentally allowed the virus to cross the border and to take root in Taiwan. This eventually triggered a succession of domestic transmissions.
At that moment, due to Taiwan’s exclusion from the WHO, we were unable to acquire information regarding SARS or to get any other assistance directly from the international health community. This situation created a severe bottleneck in Taiwan’s virus inspection and disease control efforts, and fostered panic that grew among the citizens. During that time, when anyone let out a single cough, the whole crowd nearby would be thrown into a panic for fear of being infected by the SARS virus; the terrified citizens even snapped up every surgical or facial mask they could find in the local drug stores. For the entire spring, there were almost no smiles to be seen in Taiwan. Instead, millions of white surgical masks covered the faces of people in the streets. Many businesses that could not handle the heavy loss closed their doors. If Taiwan was a WHO member state, and if it had received assistance when the first case came into the country from abroad, the subsequent epidemic would most likely not have been so serious.
Under this situation, the Taiwan government quickly mobilized its system of public health and epidemic control and organized experts and academicians to form a « SARS Prevention and Treatment Expert Commission. » By quarantine measures and temperature-taking efforts, we finally brought the epidemic to the end.
During the SARS epidemic, people, including me, tried to protect ourselves by keeping good hygienic practice and by taking preventive measures such as frequently washing our hands and taking temperatures twice daily. At that time, I and my colleagues were placed under tremendous pressure and were forced to gamble with people’s lives as they raced against the virus. I am proud to say that the spirit of our profession and the dedication shown by so many in the medical community, who worked under great stress at life-threatening conditions, were honored nationwide.
What would you say are the main lessons learned from SARS?
The world learned a hard lesson from the crisis of SARS. It was caused by the lack of resources and experience in combating the deadly contagious disease that claimed 800 lives and traumatized the entire world.
The SARS epidemic has proven Taiwan’s resilience. Originally, the Ministry of Economic Affairs estimated that losses caused by the epidemic would reach NT$250 billion. Final calculations showed that the actual losses were only NT$900 million. This can be attributed to the high quality of Taiwan’s medical and public health systems, which made it possible for the country to regain its footing in a short time. The Taiwan people also gained many valuable experiences from the crisis. The CDC, for example, learned how to control infections in laboratories and it also established a set of standard operation procedures, for which even the WHO Western Pacific Regional Office made a request for the reference, so that it could serve as a reference for other countries to conduct inspections on the laboratory spread of the disease.
In Taiwan’s 100-plus-day life-or-death war against SARS, we not only learned many experiences and new techniques, strengthened organization and coordination, and developed more tolerance and concern among people, but we also acquired the wisdom for understanding nature and life. With this kind of understanding, as we mourn for those who lost their lives and hail those who struggled bravely, let us look fearlessly to the future.
The epidemic raged from late March to early June, striking terror in residents’ hearts, bringing commercial activities to a halt, and plunging virtually the entire society into upheaval, adding a chapter to one of the worst tragedies to Taiwan’s medical history.
The most important lesson is that in this age of globalization, the health of the people of Taiwan is closely bound up with people around the world. The SARS epidemic demonstrates that the WHO ought to seriously consider admitting Taiwan as a member. No country or region can be excluded from the global health and disease prevention network, and no gap can be allowed to persist in the epidemic prevention system.
Last year the avian influenza disease was making the headlines all over the world. Do you really think there is a real danger? And how do you cope with the threats?
From the Black Death of the Middle Ages, to the smallpox epidemic that wiped out half the population of the Aztec Empire, to the Spanish influenza that took 20 million lives from around the world in 1918, history has shown us what epidemics are capable of. We should never under-estimate any epidemic, even a potential one. Especially since several experts have pointed out chilling parallels found in the virulent strain of avian flu H5N1 and that the genetic makeup of the H1N1 strain was responsible for the 1918 flu pandemic. The proliferation of H5N1 is of grave concern for human health for three fundamental reasons. The first reason is the documented ability of the avian pathogen to directly transmit from birds to humans. Second, when contracted by human beings, H5N1 has a 50 percent fatality rate. Third, it is not unlikely that the virus will acquire a mutant or recombinant gene so that the virus will become transmittable from one human to another, thereby multiplying the threat to human lives exponentially. These three reasons indicate the potential of H5N1 to ignite a severe pandemic.
Taiwan copes with the threats of the avian influenza by regular and additional surveillance and by taking preventive measures in the bird population. Moreover, our Coast Guard and the Customs cooperate to crackdown on the smuggling of animals and animal products. We have also strengthened communication with the public about our surveillance program and with the dangers of smuggled animal products.
Medical doctors are supposed to assist everybody, no matter what their religion, color, etc. is. How does it feel not to be able to be part of the « in crowd » if I may put it this way?
While the global community is promoting the ideas of « health care with no borders » and « human rights with no national boundaries, » Taiwan remains callously isolated. This is absurd and senseless. On the other hand, because of Taiwan’s exclusion from the global health community, the gap in the international epidemic prevention network becomes a great cause of concern, as reflected in Taiwan’s case in the outbreak of SARS in 2003.
The International Health Regulations (IHR) were adopted by the World Health Assembly and came into force on June 2006. What are your concerns and how will you face these?
Although Taiwan is not a member of the WHO, Article 2 of the IHR states clearly that the purpose and scope of these regulations are to prevent, to protect against, to control and to provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade. As a member of the World Trade Organization (WTO) and as the 16th largest trading nation on the globe, Taiwan has the responsibility to help ensure sound public health practices without disrupting international trade and traffic directly linked to Taiwan.
Another serious concern is that the international community may include Taiwan in China’s implementation of the IHR based on China’s false claim of Taiwan as being one of its provinces. China has long been known for intentionally disclosing or delaying the public health information to serve its political purpose. For example, in the initial stage of SARS epidemic in 2003, China intentionally disclosed information about its SARS cases from the world, causing the epidemic to quickly spread to Hong Kong, Canada, Vietnam and Singapore. Also, in September 2007, INFOSAN didn’t pass to Taiwan the information that baby corn exported from Thailand was potentially contaminated with the Shigella sonnel pathogen. Political manipulation imposed from China in this case, was a great insult to Taiwanese health rights. This situation could result in serious consequences and must be avoided in the future.
It is clear that the IHR are needed to help ensure that the earliest epidemiological signals of increased transmissibility of the virus among humans are not missed. And we are aware that several provisions in the IHR would be useful in ensuring a strengthened and coordinated response on the part of the international community both to the present situation and to a possible pandemic. Taiwan already declared its voluntary early compliance with all the provisions of the IHR 2005 to ensure optimal national and global health security. The WHO should be encouraged to have direct access and communication with Taiwan.
Finally, if you had a message to the international community, what would that be?
In the era of globalization, « borderless medical health and zero tolerance in disease prevention » has taken center-stage. Taiwan, as a member of this global community, cannot be excluded from the international health society. Although Taiwan is not a member of the WHO, it always makes its best endeavors to advance international medical and health cooperation. In order to further integrate Taiwan’s abundant medical resources, Taiwan International Health Action (TaiwanIHA) was established to allow Taiwan to play a greater role in global health affairs. As convener of TaiwanIHA, I am so proud to say that TaiwanIHA has achieved great accomplishments and has made valuable contributions to the international community. For example, our medical and rescue personnel were often the first to arrive on the scene to the recent tsunami in Southeast Asia, to earthquakes in the Solomon Islands, to Indonesia and Peru, and to the landslide in the Philippines. Also, the avian influenza prevention work in Burkina Faso and Chad, the HIV/AIDS prevention program in Malawi, and the nursing leader training and CAM/TM programs for our friendly allies were highly recognized and appreciated.
However, while domestic disease prevention work can be accomplished through the will of the government and the people, international disease prevention requires the coordinated efforts of international organizations. A lack of WHO participation results in Taiwan’s inability to effectively share its health-related experiences, manpower, and other resources with the international community. Subjecting the Taiwanese people to a form of « health apartheid » is not only morally wrong, but it is also inconsistent with the ideals and commitment that are very fundamental of the entire WHO system. This de facto health care segregation also seriously weakens the international disease prevention network. We hope that Taiwan’s efforts will make the international community recognize the health and well-being of the 23 million people who live here. We also hope that the world will allow Taiwan to have the same human right to health security as other countries, and to allow Taiwan to share its valuable experiences as part of its role as a member of the international community. We hope the international community will be able to hear the heartfelt voices of 23 million Taiwanese and soon extricate itself from the web of political obstacles and make the funding goal of the WHO, « attainment by all peoples of the highest possible level of health », a genuine reality.
