key: cord-0730046-c7a5u9it
authors: Kim, Jaewan; Moon, Jongwoo; Jung, Tae Yong; Kim, Woojin; Yoo, Herim Clara
title: Why Have the Republic of Korea, Taiwan, and Singapore Coped Well with COVID-19 and What Are the Lessons Learned from Their Experiences?
date: 2022-02-17
journal: Yonsei Med J
DOI: 10.3349/ymj.2022.63.3.296
sha: e00ba8ddd944061559707e224e88380678fefa4c
doc_id: 730046
cord_uid: c7a5u9it

This study investigated how three Asian countries–Republic of Korea (ROK), Republic of China (Taiwan), and Singapore–considered as standouts, responded to the coronavirus disease 2019 (COVID-19) in terms of governance system, health sector innovation, and social distancing to draw lessons that other countries can learn from. The countries were commonly in success of the response in early stage of the pandemic thanks to their effective and efficient strategies paired with advanced information and communications technology (ICT). Consequently, the three jurisdictions reported lower confirmed cases as well as fatality rate of the infectious disease compared to other high-income countries. In addition, the countries’ previous experiences with other pandemics, including influenza A, Middle East respiratory syndrome, and severe acute respiratory syndrome, enabled them to establish resilient public health systems and gain public acceptance to governmental control or surveillance during national infectious disease-related crises outbreaks. Advanced ICT infrastructure and digital technology were used as effective tools for testing, tracing, and treatment of the pandemic in collaboration with the private sector as a crucial player. The ROK, Taiwan, and Singapore adopted different strategies between containment and mitigation policy to flatten the epidemic curves effectively according to their own situation and judgement. Despite the exemplary aspect of the three nations in coping with the COVID-19 pandemic, a few limitations were also observed in terms of vaccination and unequal consequences of the pandemic among people. These should be further discussed in order to be prepared for future pandemics.

cases due to the Delta variant both in Taiwan and Singaporewhere nearly zero and single-digit COVID-19 cases were reported since the beginning of 2021-has placed the nations in jeopardy, the accumulated numbers still seem small in comparison to global standards. 5 We investigated the three nations' responses to COVID-19 considering their governance system, health sector innovation, and social distancing to assess the common factors that lead the countries to their relative successes in coping with the pandemic in early stage (Table 1) . Furthermore, we addressed the drawbacks found in each country's COVID-19 response, so that lessons can be learned and taken into account in future actions. The countries' experiences and remarkable progress during the COVID-19 pandemic situation can be drawn into useful strategies that other countries can adopt for future pandemics. The study used information and data provided by national and international organizations (Supplementary Material, only online). Table 2 details the key epidemiological features of the COV-ID-19 response, socio-economic conditions, and general medical infrastructure situation in the three countries. All three nations share similar characteristics in many aspects of tackling the COVID-19 situation, and the study focuses on these distinguishing features. Fig. 2 3, 4, 6 shows the key trends of the COVID-19 situation (cases confirmed, fatality rate, and vaccination) in the three countries. In terms of daily confirmed cases per million people, Taiwan had maintained a remarkably low number of cases since the outbreak of the pandemic until the Delta variant stroke the island in mid-May 2021. However, Taiwan successfully managed to reduce the daily confirmed cases from 597 on May 28 to a low of 30 cases on July 12, 2021. 3 As shown in Fig. 2 , Singapore had a notably low fatality rate at 0.26% compared to other two countries. This was because about 95% of the COVID-19 infections on the island were confirmed in young migrant workers living in cramped dormitories. 7 For the vaccine drive, all three countries were not doing particularly well at the initial stage of the pandemic. The countries had limited vaccine supplies, unlike countries like the US, UK, and China that have the capability to produce their own vaccines. 5 While Singapore achieved a full vaccination rate of 60% by July 2021, ROK only reached to the same stage in October, and Taiwan is still struggling to provide vaccines to its citizens. According to Our World in Data, the percentage of the population who are fully vaccinated was 79.11% in the ROK, 48% in Taiwan, and 91.91% in Singapore, as of November 22, 2021 (for Singapore, November 5, 2021). 6 There are a few major factors that led the ROK, Taiwan, and Singapore to cope well during the COVID-19 pandemic. First, the three countries have commonly experienced pandemics in the past. The wearing masks, screening travel record, social distancing, 14-day closing upon confirmed cases Both Taiwan and Singapore had severe acute respiratory syndrome (SARS) outbreak in 2003, with thousands of cases and many deaths in both countries. 9,10 Consequently, these experiences paved the way for the nations to establish robust public health systems, including a legal framework for accessing private information with fewer objections regarding breach of privacy, strengthening a dedicated national agency for control and prevention of infectious diseases, and maintaining transpar-ency in responding to the pandemic. Regarding the ROK, the Korea Disease Control and Prevention Agency (KDCA) is the primary body for infectious disease prevention and control. However, during national infectious disease-related crises, the Central Disaster and Safety Countermeasures Headquarters (CDSCH) is established and operated as an ad hoc disaster control tower with either the Prime Minister or the Minister of Interior and Safety as the head. 11 The Central Epidemic Command -(+/-) Home-based learning: due to the recent spike in virus cases, full home-based learning began on May 19, 2021 -(+) When on campus, mask wearing, temperature check, and using hadn sanitizer required -(+) Personal laptop or tablet to all secondary school students for online learning, and lectures and tutorials at third-level institutions online -(+) Investment plans for teachers and key education staffs to enhance their capacity Centre (CECC) in Taiwan played a leading role in responding to the pandemic in conjunction with the Taiwan Centers for Disease Control. 1 In Singapore, the National Centre for Infectious Diseases (NCID) has been instrumental in strengthening the country's capabilities in infectious disease management and prevention. 12 Therefore, the resilient public health systems and public cooperation in all three countries have helped limit the spread of COVID-19. Second, the three countries have developed advanced ICT infrastructure and digital technology that can be strategically used for effective disaster response in terms of testing, tracing/ tracking, and treatment/management, as seen during the CO-VID-19 pandemic. The KDCA has developed the COVID-19 Smart Management System-an epidemiological investigation support system-to provide the location of confirmed cases within 10 minutes using big data gathered from the use of credit cards, mobile phone location data, closed-circuit television footage, etc. 13 Taiwan adopted extensive contact tracing based on the travel history of individuals from Customs and Immigration to be linked to their National Health Insurance card. 1 Singapore developed the TraceTogether Programme, whose app and token can identify people who were in proximity to an infected person. This helped prevent the disease from spreading in clusters. 14 Furthermore, digital media was used to assure the pop-ulation of these countries that their governments were in control of the pandemic situation. In this process, the private industry became a critical player; for instance, in test kit development, creating a tracing app based on application program interface data, meeting the intensive demand for personal protective equipment (PPE) and other medical supplies. Rapid cooperation between the government and private sector enabled the countries to quickly respond to the COVID-19 outbreak. 15 Third, all three countries share significant components of the 3Ts (Test, Trace, and Treatment) in coping with the pandemic in the health sector. For testing, systemic testing with diagnostic kits that show results in less than 4 hours have been developed and implemented. In the ROK, the KDCA supported and rapidly approved the agile participation of the private sector to develop a real-time polymerase chain reaction (RT-PCR) method, which allowed massive and efficient nationwide virus testing. 16 Additionally, new types of inspection systems, such as drive-throughs or walk-throughs, have been established for large-scale rapid inspections. In Singapore, massive testing was conducted in the early stage of the pandemic, and several CO-VID-19 test kits, such as the Veredus Laboratories' VereCoV detection kit, A*STAR, and TTSH's Fortitude Kit 2.0, were developed. These kits proved crucial for Singapore to contain the outbreak of the virus at an early stage. 17 While Taiwan initally implemented the testing method of RT-PCR and antibodies on a limited scale, the unprecedented spike of virus cases in May 2021 necessitated the establishment of COVID-19 testing stations all over the island. 18 In terms of treatment, the Ministry of Health and Welfare (MOHW) in the ROK had focused on reshaping the hospital system after facing the MERS outbreak, which was mostly linked to hospitals, in 2015. 19 The National Safe Hospital was designed to separate patients with respiratory diseases from other patients throughout the entire treatment process. Moreover, the ROK increased patient care capacity by designating public facilities as residential treatment centers that only manage patients with mild COVID-19 symptoms. 20 However, the supply and demand of face masks in the early stage of the pandemic were not smooth in the ROK, which led to the implementation of the mandatory public supply of masks, mask rationing based on a 5-day rotation mask distribution system, and restricted mask exports to overcome the mask shortage. 20 In Taiwan, the extensive infectious disease network for effective treatment of the pandemic, including selected hospitals, health systems, private clinics, and local health departments across the island, coordinated emergency facilities when an emergency response was needed. For the safety of medical staff working at the frontline, the CECC reserved PPEs for up to 2 months. 18 Taiwan's Ministry of Economic Affairs imposed a ban on exports of face masks on January 24, 2020 in order to assure sufficient domestic availability. Based on the Name-based Rationing System, Taiwan also restricted the number of face masks purchased by each citizen. Similarly, in Singapore, the NCID-a 330-bed purpose-built facility-strengthened Singapore's capabilities in the management and prevention of infectious disease. Moreover, since the experience of SARS in 2003, a national stockpile of PPEs, critical medications, and vaccines were secured in advance for up to 6 months after the virus outbreak. 21 The government recognized the shortage of masks among the general public; therefore, Singapore's leaders originally urged citizens to wear masks only if they were already ill, until the beginning of April 2020. However, Singapore's Ministry of Health recommended that "masks will now be required as the default" from June 2020, due to their effectiveness to prevent the spread of the virus. 22 Lastly, the citizens of ROK, Taiwan, and Singapore followed the social distancing guidelines issued by their governments, thus lowering the rate of community infections. The three countries share the same cultural roots of Confucianism, which indicates culture as a driver of relatively successful responses to the pandemic in Asian countries compared to the West. Confucianism emphasizes one's duties to family and society over individual rights, which has resulted in public acceptance of a great degree of governmental control or surveillance. 23 For example, mask wearing imposed by authorities and patient tracing based on collected personal information were accepted by the public without strong objection in these three countries.

The three countries' cases provided significant lessons indicating that the containment and mitigation strategies in dealing with COVID-19 have been effective in flattening the epidemic curves. To restore society, the most beneficial and least costly measures should be adopted after reopening borders and economies. 24 The ROK has neither imposed a draconian lock-down nor stringent border control as a response to the pandemic, whereas Singapore opted for the opposite with two circuit breakers and strong border control. Taiwan never had to go into lockdown until the outbreak of the COVID-19 variant in May 2021, but focused on early and strict border controls with a ban on foreign visitors. 5 Whether the virus response involved containment strategy or mitigation policy, what is important is that all three countries succeeded in their initial response to the COVID-19 pandemic. 25 Despite exemplary aspects of the three countries in their response to COVID-19, there are a few issues that should be discussed to better prepare for any future pandemic. One of the major issues is vaccination. Since the COVID-19 situation in the three countries had been relatively stable as compared to other high-income countries around the world, there was not enough motivation to take a risk possibly expected from vaccination. However, a drastic rise in virus cases since May 2021 has changed the public sentiment. Still, there was not enough stockpile to go around in the begining. 5 Moreover, COVID-19 increased the vulnerability of society, especially among the socially and economically disadvantaged. 26 The pandemic also worsened income inequality in the ROK due to social distancing rules. The Gini coefficient of the country rose by 0.009 points in 2020. 27 In Singapore, large infection clusters were found in cramped dormitories of foreign workers who were hired on work permits for construction, cleaning, and service sectors. 7 This showed ongoing inequalities within the society.

In this study, we discussed the effective responses of ROK, Taiwan, and Singapore to COVID-19 through three different perspectives-governance, health, and social distancing. Most of all, these countries took appropriate initial countermeasures to control the spread of COVID-19. However, various non-pharmaceutical interventions (NPIs) in the early stage of the pandemic were criticized due to the enormous socio-economic losses. Therefore, a suitable combination of NPIs with less disruptive and costly measures is essential for countries to forecast the effectiveness of future interventions. 28 The pre-COV-ID-19 preparation based on previous experiences equipped the three aforementioned jurisdictions with resilient public health systems and advanced ICT infrastructure. Public acceptance based on the Confucian culture helped authorities to swiftly implement control and prevention measures. Nevertheless, the three countries still have to improve in terms of vaccination as well as inequality as seen during the COVID-19 situation to be better prepared for any future pandemic.

Herim Clara Yoo https://orcid.org/0000-0003-2166-1775

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The authors appreciate the support from the Asian Development Bank (ADB) in partnership with the Ban Ki-moon Foundation for a Better Future (BKMF) in developing this knowledge product. We gratefully acknowledge Ms. Hyerin Bang and Ms. Hanyi Kim for their support for the collection of data and information of the case studies.