Tim Culpan: Skip Covid-19 denial and stop the dying

Five stages of epidemic control show how a society like Taiwan, badly hit by Sars in 2003, can survive this viral outbreak. Other countries must now do the same, writes Tim Culpan.
Tim Culpan: Skip Covid-19 denial and stop the dying

Five stages of epidemic control show how a society like Taiwan, badly hit by Sars in 2003, can survive this viral outbreak. Other countries must now do the same, writes Tim Culpan.

Taipei medical workers in full protective body suits at an infected housing complex in Taiwan in 2003 during the Sars epidemic.
Taipei medical workers in full protective body suits at an infected housing complex in Taiwan in 2003 during the Sars epidemic.

WHAT Taiwan learned: Quickly admit the problem; then you can deal with it.

In late May 2003, I had to go to a funeral. The deceased was the head nurse at a hospital in Taiwan. She died from severe acute respiratory syndrome — Sars.

I’d never met her. I was there in my capacity as a reporter, trying to observe, to learn, to stay out of the way.

Sitting at the back of the funeral hall was the head of her hospital. Mask on. Forlorn. He knew the role he’d played in her death.

His denial that there were new cases of the virus had led to a wider outbreak.

The nurse was one of 73 people who died from 346 cases in Taiwan, making it one of the worst-hit places from the fast-moving, lethal disease that claimed more than 770 lives in 17 countries.

The tragedy, culminating in a white-clad funeral hall, was a case study in what I now see as a pattern in how societies deal with impending epidemics, and is of crucial importance as the world grapples with the coronavirus called Covid-19.

Echoes of Taiwan’s previous mistakes rang out in January this year in Wuhan. One of the earliest voices to warn of a strange new respiratory illness was a doctor chastised by authorities who didn’t want to face the reality of what was happening. It was only after Li Wenliang’s death that the government joined citizens in lauding his work.

By burying their heads in the sand, Beijing and the local government failed. They compounded that mistake through censorship and evading the truth. Authorities tried to rectify their initial mistakes with draconian measures, including shutting down the entire city of Wuhan.

China isn’t alone in struggling to adapt to this disaster. Countries around the world — from Iran and Italy to South Korea and Japan and the US — are going through elements of the same cycle.

In 1969, psychiatrist Elisabeth Kubler-Ross described the now-famous five stages of grief experienced by terminally ill patients: Denial, anger, bargaining, depression, and acceptance.

Though not precisely the same, I’m seeing similarities to how societies handle an epidemic crisis.

How fast they work through the stages will determine how well they fight Covid-19.

  • Almost everywhere, first, there has been internal denial: Authorities or populations don’t believe it’s real, despite what they’re told by people who know better;
  • The next step is external denial. Under authoritarian regimes, this comes in the form of censorship. In open societies, it’s attacks on message-bearers, including media and experts. In some places, it’s a mix of both;
  • Third comes action. Sometimes over-reaction. Sometimes brutal, desperate or flailing. But eventually the mechanisms of authority get put to work in tackling the outbreak. How successful they are depends on how quickly they got through these first three stages.
  • Then comes the blame game. Governments, media, victims, experts, and the public all point fingers. In Taiwan during the Sars era, that blame rested firmly on the shoulders of a few health officials.
  • Then, the fifth and final stage, when people are ready to believe that the worst is over, comes self-congratulation at a job well done.

President Xi Jinping’s visit to Wuhan this week is part of the broader propaganda campaign aimed at glorifying the Chinese government’s efforts.

By late April 2003, Taiwan knew Sars was a problem.

The pneumonia-like illness had already popped up in mainland China and spread to Hong Kong, reaching Taiwan by early March. Further imported cases had put health authorities on alert. But the president of Taipei Municipal Hoping Hospital got caught up in denial, delaying action.

“A lapse in infection control in a single hospital allowed the outbreak, which had been under good control, to escalate,” David Heymann, the World Health Organisation’s executive director for communicable diseases, later wrote of Taiwan’s experience.

By the time of the funeral service, the hospital president had been fired. Also losing his job was the health minister, replaced by a respected Johns Hopkins University-trained epidemiologist, Chen Chien-jen.

Taiwan has one of the lowest Covid-19 case counts in the rest of the world helped by early recognition and action against the potential threat.

TAIWAN’S strength is its open society. Political institutions have matured a lot in the past 17 years and where democracy means that citizens have a real connection to their representatives.

Experts are respected — and president Tsai Ing-wen is a former professor. The vice-president is that same respected epidemiologist: Chen Chien-jen.

On January 20 this year, Taiwan’s Centres for Disease Control activated its Central Epidemic Command Centre to co-ordinate efforts against the new virus.

That was three days before China put Wuhan on lockdown and the first meeting of the WHO’s emergency committee. Significantly, it came before Taiwan had even recorded its first case.

The government skipped quickly through the internal and external denial phases.

    Useful information
  • The HSE have developed an information pack on how to protect yourself and others from coronavirus. Read it here
  • Anyone with symptoms of coronavirus who has been in close contact with a confirmed case in the last 14 days should isolate themselves from other people - this means going into a different, well-ventilated room alone, with a phone; phone their GP, or emergency department - if this is not possible, phone 112 or 999 and in a medical emergency (if you have severe symptoms) phone 112 or 999

While many Taiwanese were yet to be convinced about the dangers, most trusted that the actions taken, such as temperature checks at buildings and use of masks, were reasonable.

A shortage was alleviated when volunteers, and then the government itself, started collating and publishing locations and inventories of masks so people knew where to shop.

The result was caution, rather than panic.

Other societies are going through the cycle of crisis in different ways. Italy moved through denial pretty quickly, with prime minister Giuseppe Conte putting his entire nation on lockdown and acknowledging “we need to change our habits right now”. South Korea’s government jumped into action while Hong Kong fumbled early on.

The situation looks more bleak for countries like Iran and the US which haven’t fully broken out of stages one and two.

Eventually they will, because denial can only last so long.

Circumstances will dictate action. The only question is how quickly.

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