“The first time it’s a novelty. The second time, people know what they’re in for and are less willing to take another hit. The virus is exposing socioeconomic fault lines: it’s harder to stay home with a head cold if you work casual shifts for minimum wage and can’t afford to miss a few days.” (Bloomberg Prognosis column, August 1, 2020)
On July 11, in a COVID-19 briefing held at Blake Medical Center in Bradenton, Florida, Gov. Ron DeSantis bragged about the amount of coronavirus testing Florida has done compared to Taiwan.
He said, “We’ll go over some of the things we’re doing in terms of the COVID-19 response. Of course, our mission really focuses on protecting the vulnerable. We’ve from the very beginning wanted to expand testing. We are definitely doing that. Two days – yesterday – we reported 95,000 tests; today I think we’re over 80,000 tests. To put that in perspective, Taiwan has done 78,000 tests the entire pandemic, and they are 23 million people, so we’re definitely doing a lot of testing, practicing social distancing, and supporting and protecting hospital and healthcare workers.”
Ron DeSantis’s comparison between Florida and Taiwan caught our attention, so we would like to follow his lead by delving into Taiwan’s COVID-19 story a little further.
Taiwan launched its response to SARS-CoV-2 on December 31, 2019, the day that China announced an unknown pneumonia circulating in Wuhan. Taiwanese officials began screening travelers from Wuhan that day, before passengers deboarded planes. The island, which is situated just 81 miles from China, ramped up its efforts to arrest spread of the virus in January, requiring a 14-day quarantine for everyone who had visited Wuhan within 14 days. Travel from China’s Hubei Province was restricted in late January, and those restrictions were expanded as outbreaks surfaced elsewhere.
Taiwanese officials leveraged data analytics to identify possible cases through the national healthcare system. Travel data was integrated with health data so a doctor seeing a patient would have that patient’s travel history. People deemed at high risk because of their recent travel history were asked to stay at home and were tracked through their cellphones.
Limits were set on mask prices in January; masks sales were rationed in February (at first, two per week and then three) to prevent hoarding and ensure access; and exports of masks were halted to secure domestic supply. Taiwan’s residents could see on a map where pharmacies were located and which pharmacies had masks in stock. Residents almost always wore masks in public spaces.
Taiwan prepared to provide assistance to schools, though schools never had to close; it used government and military funds to ramp up the production of masks; it oversaw resource allocation; it fought misinformation and issued public service announcements and made plans to assist schools, businesses, and furloughed workers.
Please let me insert a Kotok personal note about this timeline: On March 1, I sat at a private dinner in Sarasota when an email about the first Covid case in a hospital in Sarasota flashed on a device; within 48 hours it was statewide news in Florida. I wore a mask as a speaker at the global ETF conference in Ft. Lauderdale in January, 2020. I don’t know what Governor DeSantis knew and when he knew it. I do know that a lot of other folks were well aware of the Taiwan timeline by early January.
Back to Taiwan.
In fact, the list of actions that Taiwan took during the first two months of the pandemic runs to five pages long and is available as a supplement to a JAMA study, published on March 3, 2020, which concludes, “Through early recognition of the crisis, daily briefings to the public, and simple health messaging, the government was able to reassure the public by delivering timely, accurate, and transparent information regarding the evolving epidemic. Taiwan is an example of how a society can respond quickly to a crisis and protect the interests of its citizens.” (https://jamanetwork.com/journals/jama/fullarticle/2762689)
By April, Taiwan was requiring masks on public transport and closing hostess clubs and ballrooms. Still, Taiwan’s residents were able to retain most of their freedoms, avoiding the full shutdowns many nations experienced. (By all accounts, they did not consider a face covering tantamount to enslavement.) By the end of the month, although Taiwan had to deal with an outbreak aboard a naval vessel, the virus was under control and Taiwanese citizens were permitted to donate their allotments of masks to other countries in need. By May 1, there had been no cases for six days. It was possible to hold a baseball game with 1000 spectators the next week, though restrictions on mass gatherings continued and an annual Buddha Day celebration was moved online.
On May 11, Taiwan reported a coronavirus death, bringing the island nation’s total death count to 7. (By the end of the day on May 11 in Florida, by contrast, 1735 Floridians had died.)
On May 21, a single new case was reported in Taiwan. On that same day in Florida, 527 new cases were confirmed. That number exceeds the total number of cases recorded in Taiwan, which stands at 467 on July 30. Florida’s official total number of cases as of July 30 was 461,379, or nearly 1000 times higher than Taiwan’s.
In early June, given that no local transmission of the virus had occurred in 56 days, some restrictions on mass gatherings were lifted, and later in the month, Taiwan eased travel restrictions for business travel and other purposes from some countries, with testing, screening, and quarantine requirements. (See “Entry restrictions for foreigners to Taiwan in response to COVID-19 outbreak,” https://www.boca.gov.tw/cp-220-5081-c06dc-2.html. Sources for the timeline from April until the present are “Timeline: COVID-19 in Taiwan,” Focus Taiwan,https://focustaiwan.tw/society/202004185001, and Worldometer,https://www.worldometers.info/coronavirus/.)
Just as the COVID-19 stories of Florida and Taiwan have diverged, so have their economic stories. US Fed Chairman Jerome Powell warned on July 29, “The path of the economy is going to depend to a very high extent on the course of the virus, on the measures that we take to keep it in check. We can’t say it enough.” (“Fed Maintains Stimulus Commitment as Economic Outlook Dims,” https://www.wsj.com/articles/fed-maintains-stimulus-commitment-as-economic-outlook-dims-11596045601). For now, with US cases and deaths surging, the recovery that reopening was meant to achieve is floundering.
Meanwhile, though Taiwan took its own COVID-19 lumps during the second quarter, Taiwan’s budget office now forecasts that the country will see 1.67% growth for 2020 (“Taiwan Reaping Rare Economic Benefits Due To Its Successful Battle Against Covid-19,”https://www.forbes.com/sites/ralphjennings/2020/07/24/taiwan-reaping-rare-economic-benefits-of-its-successful-battle-against-covid-19/#3cf41d44329d). The Brookings Institution offers further analysis of COVID-19’s impacts on Taiwan’s economy here: “Taiwan faces a changed economic outlook in Asia following COVID-19,” https://www.brookings.edu/blog/order-from-chaos/2020/06/29/taiwan-faces-a-changed-economic-outlook-in-asia-following-covid-19/.
This huge, tragic difference in outcomes points up a key lesson in pandemic response: Leadership matters. “They have professionals running the show,” says Tsung-Mei Cheng, a health policy research analyst at Princeton University. “These are people who have trained for years for this.” (“How Taiwan beat the coronavirus,” CNBC, https://www.cnbc.com/2020/07/15/how-taiwan-beat-the-coronavirus.html)
Taiwan’s government had a strong pandemic management plan, which was put in place after Taiwan suffered greatly in the SARS epidemic of 2003. The plan was strictly enforced, and the public respected the rules and obeyed them. “We have this phrase in Taiwan that roughly translates to, ‘This is your country, and it’s up to you to save it,’” Cheng said. People caught not wearing masks in crowded areas, such as the subway, or who break quarantine are hit with huge fines and may find themselves shamed on social media.
In a comment posted on March 5 in response to the JAMA article cited above, expat Lloyd Lalande, who teaches at Taiwan’s Tzu Chi University, noted the nation’s solidarity in fighting the virus and observed residents’ trust of a trustworthy government: “There has definitely been a sense here that the COVID-19 threat has and continues to be managed competently by the government with community members also responsibly and cooperatively playing their part. That response is visible everywhere, whether coming through immigration control, having my temperature checked each time I enter my campus, using the alcohol hand spray at my favorite coffee shop, or buying masks with my residential card….” (“Response to COVID-19 in Taiwan Big Data Analytics, New Technology, and Proactive Testing,”https://jamanetwork.com/journals/jama/fullarticle/2762689)
Meanwhile, in Florida, Gov. DeSantis has maintained that mandating masks statewide just wouldn’t work. “To do police and put criminal penalties on that is something that is probably gonna, would backfire,” DeSantis said on June 26 (West Palm Beach TV, https://www.wptv.com/news/state/mandating-masks-statewide-would-backfire-florida-gov-ron-desantis-says). Across Florida, trust in state leadership is low, and noncompliance with public health recommendations is problematic. (Meanwhile, the evidence for masks mounts, as the Wall Street Journal reports here: “Face Masks Really Do Matter. The Scientific Evidence Is Growing,” https://www.wsj.com/articles/face-masks-really-do-matter-the-scientific-evidence-is-growing-11595083298.)
The governor, for his part, has blamed Florida’s record-breaking spike in COVID-19 cases on increased testing, a theme borrowed from President Trump.
Governor DeSantis is correct about the number of COVID-19 tests Florida has done relative to the number Taiwan has done. But if, like Taiwan, you don’t have many cases anymore because you have almost completely stamped out the virus, you don’t have to do nearly as much testing as you must if your ICUs are full and the number of people you have dying every day is equivalent to a commercial jet crashing with no survivors every single day.
In closing, we offer a Twitter thread on why we need even more testing than we have, posted by Natalie Dean, an assistant professor of biostatistics at the University of Florida:
[Begin thread – adapted for readability here]
THINK LIKE AN EPIDEMIOLOGIST:
The chart below is tests per 1000 people. Relative to other countries, the United States is doing a lot of testing. So why do public health experts say that testing is inadequate in the USA
First, the amount of testing a country needs is not fixed, but rather it depends on the size of that country’s outbreak. South Korea does not need to do the same amount of testing as the United States because our outbreak is much bigger than theirs. For starters, we need enough testing to meet demand, and demand will depend on how many people are sick with COVID-like symptoms or have been exposed to an infected person. With hot spots everywhere, there is much more demand in the US. In addition, for the same amount of testing, many more of our tests come back positive. This is reflected in higher test positivity (>5%). High test positivity implies that we need more testing to uncover more of the infections that are being missed. Here we see daily tests per million (y-axis) against confirmed cases per million (x-axis). Countries at the same height are doing a similar amount of testing, but the US is far off on the right with a larger outbreak and higher positivity.
The other major reason that public health experts are concerned about testing? Long turnaround times! These tests get counted in the official statistics whether it took 1 day or 14 days to get the results. But only the quick turnaround times are useful for control efforts. So while we may be doing a lot of testing on a per capita basis, it is still not adequate because:
- Our outbreak is very large
- Our test positivity is too high
- Out test turnaround times are too slow
[End thread] (https://twitter.com/nataliexdean/status/1288179530264272897)
I thank Governor DeSantis for inviting us to pursue an illuminating comparison of COVID-19 responses and outcomes in the State of Florida versus Taiwan, a nation with a population of similar size. I believe that Florida has options other than the COVID conflagration that we see burning through our population. Governor DeSantis’s flagging approval numbers, which have fallen from 62% to 45% since last year, confirm that I am not alone in my grave concern for our state and the policy path we are on (“Florida Gov. Ron DeSantis’ popularity plummets amid widely panned coronavirus response,” https://www.usatoday.com/story/news/politics/2020/07/31/covid-19-florida-gov-ron-desantis-popularity-polls-plummets/5559026002/).
My company relocated to Florida a decade ago. Forty of us work here. We touch hundreds of people directly in our company and thousands of Floridians in our state. We are watching our state government fall short of the response that this crisis demands while our businesses struggle and our investment risk rises.
For me personally, this statewide failure is a disappointment in both civics and in public health. In civics, and as a veteran of New Jersey Republican politics (I served two Republican governors, had two Senate confirmations and four Republican appointments), it was not in our early political teaching to see disregard for the safety of a state’s citizens. In my government experience, that came first, not partisan politics.
For business, I would argue that we have to change course, or we will not get this economy of Florida fully back to work for years. This week, in Sarasota, we personally witnessed testing for COVID still delayed by nine days before results. We still have no real contact tracing mechanism. We still have no statewide requirement that residents wear masks in public. We can do better. Florida state government must do better. Otherwise, we will continue to see overburdened hospitals, more deaths, and prolonged negative economic impacts.
David R. Kotok
Chairman of the Board & Chief Investment Officer
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