What can we learn from other countries?

Deborah Nas

Countries that initiated - and maintained - a complete package of stringent measures early in the pandemic now seem to have the virus well under control. Technology can play an important role within those measures. In this context, Taiwan is being praised for its successful approach: the economy is booming and the number of infections is very low.

Every country is different. Differences in culture, norms and values and legislation mean that you cannot simply copy a technological application from another country to the Netherlands. Moreover, technology is a tool for decision-making and implementing measures. It is part of a total package: you cannot copy a single element only. Nevertheless, we can learn a lot from the experiences of other countries. From Taiwan for example, which is praised for its approach to the coronacrisis. 

Which measures did Taiwan take?

• Taiwan began screening passengers who arrived in Taiwan from or via Wuhan as early as 31 December 2019
• In mid-January, Taiwan sent two experts to Wuhan to learn more about the virus. Based on their knowledge of the SARS outbreak that hit Taiwan hard in 2003, these experts recognized the danger and sounded the alarm
• On 20 January, the Central Epidemic Command Centred was activated. This is part of Taiwan’s National Health Command Centre that was established during the SARS epidemic to combat major disease outbreaks
• Local production of face masks and other critical medical supplies was stepped up immediately
• On 21 January the first case was detected in Taiwan and from 23 January all direct flights from Wuhan were cancelled
• Travel restrictions were quickly extended

Big data for the calculation of risk scores

The activation of the Central Epidemic Command Centre made it possible to use big data to minimize the spread of the virus. Data from airline tickets that had been scanned at the airport, together with customs and immigration data, provided insights into individuals’ travel pattern in the previous two weeks. By combining this with health information from the National Health Insurance Administration, a risk score could be calculated for each individual. In other words, a big-data analysis made this possible. The risk score was shared with hospitals, general practitioners and pharmacies when people swiped their National Health Insurance smartcard. People with a high risk score were quarantined.

At the moment, Taiwanese people are subject to a complete negative travel advice. Before the travel ban, however, people with a low risk score received a border pass by text message to facilitate logistics at airports.

Geofencing and database for quarantine enforcement

Only Taiwanese people and those with a Taiwanese residence permit, diplomats and business people with a special entry permit, are allowed to enter the country. Non-residents must complete an online health declaration and provide information about their travel and contacts. Inbound travellers who show no symptoms of illness must spend two weeks in self-isolation and report their health status and temperature daily. Special quarantine taxis transport travellers between the airport and home, or to one of the special quarantine hotels; use of public transport is not allowed. Everyone receives a package including a thermometer, facial masks and usually food. If necessary, the government provides support with e.g. shopping or taking out the rubbish.

From the end of March, Taiwan has been using geofencing on mobile phones in order to maintain quarantine. This acts as an electronic fence you cannot cross. If someone who is in quarantine leaves their home or turns off their phone, a local government agency receives a message and contacts them within fifteen minutes. To prevent people from leaving their phones at home and still going out, they receive a phone call twice a day. Those who leave their place of quarantine risk a fine of up to €30,000 and placement in group quarantine.

In addition, the police can always ask people to identify themselves, even in public places. In order to identify potential offenders, the M-police system is linked to the quarantine database. Those caught in this way risk a fine of up to €90,000 or three years imprisonment.

For the geofencing functionality, the government cooperates with the country’s five mobile phone operators. If a phone makes contact with multiple masts, which is almost always the case in urban areas, mobile providers can use triangulation to determine where a mobile phone is located.

The phone needs to be turned on, but the owner of the phone does not need to make a phone call or share GPS data at that time. If the phone is turned off, this is detected immediately.

Sharing data with the public to increase alertness

At first, a press release stated where every person infected had been down to the minute. As of 20 April, an online map shows where infected persons have recently been. People who have been to the same places in the same period of time as someone infected, are advised to pay extra attention to their health and to wear a face mask.

The availability of face masks in any pharmacy in Taiwan can be found online – an initiative from a Taiwanese engineer that was quickly supported by the Minister of Digital Technology. In order to guarantee the availability of face masks, purchases are rationed. This is made possible by scanning the National Health Insurance smartcard on purchase.

Since the measures have been in place, the Minister of Health gives daily press conferences with the latest information, including where and when wearing a face mask is mandatory or recommended.

All patients are treated in the hospital

Everyone who enters the country and shows symptoms of illness is immediately transferred to hospital. If residents experience any symptoms, or observe them in others, they can call 1922, the Communicable Disease Reporting and Consultation Hotline, free of charge. Anyone with symptoms and anyone who has been in contact with an infected person is expected to get tested. If the result is positive, you will be admitted to hospital. You are only allowed to leave the hospital after three consecutive negative test results.

The effect: few infections and the economy is in full swing

Taiwan, with nearly 24 million inhabitants, is close to mainland China. The high number of flights to and from China initially increased the country’s risk profile. On 5 May, Taiwan had only 438 infections, of which 334 recovered and 6 patients died. Because the infection rate is so low, the cause of infection can be traced for each patient, so mass testing can be avoided. 

Large events have been cancelled, but otherwise people experience relatively little inconvenience in daily life. Restaurants, shops and schools are open. Public transport is running normally, but face masks are compulsory. Temperature sensors have been installed at train stations and many buildings, and hand disinfection of is also mandatory in many places.

Although Taiwan’s successful approach is interesting, we can only adopt a few elements from their approach for the Netherlands. 

The Taiwanese government allows itself the freedom to significantly restrict the privacy of its citizens in times of a pandemic. Taiwan is under normal circumstances known as a free country. It scores almost as high as the Netherlands in the Freedom House ranking (Taiwan 93, Netherlands 99) and gets a decent, albeit somewhat lower score than the Netherlands, in the Democracy Index (Taiwan 7.73, Netherlands 9.01). The curtailment of privacy in Taiwan is temporary and the government is very transparent about the use of data and its purpose. Furthermore, the daily press conferences instil confidence among residents in the government’s approach. Combined with culturally driven sense of collectivism, this ensures that the Taiwanese people observe the measures without protest.

In the Netherlands, we challenge any violation of the right to privacy enshrined in our constitution. Take as an example the discussion that arose around the app that Health Minister de Jonge wants to develop. By strictly adhering to privacy laws, the app will only be able to make a limited contribution to the scaling up of contact research by the health authorities. Another example is the fuss that arose recently about a passage from a letter that Minister de Jonge sent on 6 May:
“As the available indicators provide information with a delay, the Outbreak Management Team advises making anonymous data from telecom providers available. To this end, after consultation with the Personal Data Authority, I asked telecom providers to make their data available to the National Institute for Public Health and the Environment for Public Health and the Environment (RIVM) for the purpose of meeting the RIVM’s scientific needs”.
The immediate reaction of the Personal Data Authority was that no such consultation had taken place and that a new law would be needed for the use of such anonymised data.

There are many advantages and disadvantages to stretching the privacy rules temporarily, and the long-term effects can only be determined afterwards. We can see that Taiwan has learned a lot from the 2003 SARS outbreak. As a result, Taiwan had a contingency plan in place and could act immediately, including putting in place temporary changes in privacy legislation. This has prevented a lot of human and economic suffering.

For the Netherlands, it is the first time since the 1917 Spanish flu that we have had to deal with a pandemic. This may occur more frequently in the future, therefore it is important that we learn from the COVID-19 approach, so that we are better prepared from now on and have an action plan ready that fits our standards and values and our –  perhaps by that time adjusted – legislation.