Support Taiwan’s inclusion in the World Health Organization - Eliminate gaps in global public health

Vikrant Pachnanda comments on how Taiwan should be included in the World Health Assembly especially after the outbreak of Covid-19 from a legal perspective.

On January 30, 2020, with the worldwide outbreak of coronavirus disease 2019 (COVID-19) posing a grave threat to the health of all people, the World Health Organization (WHO) declared a public health emergency of international concern (PHEIC). At this watershed moment, WHO Director-General Tedros Adhanom Ghebreyesus has emphasized that “together, we are powerful”—yet WHO continues to exclude Taiwan from participating for political reasons, which will not only harm global disease prevention efforts, but also runs counter to Dr. Tedros’s stated vision, that “we need a WHO that belongs to all of us equally.”

Taiwan represents a potential gap in the global public health and disease prevention network

Taiwan’s location makes it a transport hub for the Asia-Pacific region. In 2019, the Taipei Flight Information Region (Taipei FIR), which abuts the Fukuoka, Manila, Hong Kong, and Shanghai FIRs, provided 1.85 million flight navigation services, overseeing flights covering more than 59.91 million instances of entry, exit, or transit by travelers (including those from China, Hong Kong, and Macao), and more than 17.1 million journeys by Taiwanese heading abroad. Such a high turnover of travelers puts Taiwan at a high risk of exposure to epidemics. However, Taiwan is unable to comprehensively participate in the multilateral public health system and network under WHO. Instead, contrary to its own wishes, Taiwan represents a potential gap in the global public health and disease prevention network, and is denied the opportunity to contribute to global public health and disease prevention cooperation.

Taiwan’s restricted participation in WHO

• COVID-19

After confirming its first COVID-19 case on January 21, Taiwan immediately followed the International Health Regulations (IHR) by reporting the matter to WHO. However, staff designated by the WHO Secretariat to communicate with Taiwan merely informed Taiwan that they would forward the information to related technical departments, and provided no follow-up information to Taiwan. Furthermore, WHO did not consent to the attendance of Taiwanese participants at three emergency committee meetings to address COVID-19. It did agree to allow Taiwanese experts to attend the related Global Research and Innovation Forum from February 11 to 12, but only in an individual capacity via videoconferencing. These experts were thus unable to engage in direct exchanges with the representatives of other countries regarding the development of the COVID-19 outbreak and related countermeasures, nor were they able to share Taiwan’s frontline experience of fighting epidemics. Furthermore, despite Taiwan’s efforts to participate in WHO technical events on epidemic prevention concerning the WHO laboratory network, no invitation has been extended to Taiwan to date.

Taiwan is the responsibility of the WHO Western Pacific Regional Office (WPRO), but the WPRO continues to refuse to contact or interact with Taiwan. Taiwan thus has no means of obtaining epidemic and other information issued by the WPRO, nor of participating in meetings organized by the WPRO. This is detrimental to Taiwan’s exchanges and interactions with the competent authorities in charge of public health in other countries throughout the region. Moreover, the IHR intranet (IHR Event Information Site) does not include Taiwan’s IHR National Focal Point information, making it more difficult for other countries’ IHR National Focal Points to contact Taiwan’s IHR National Focal Point directly, impacting the timeliness and effectiveness of bilateral cooperation in epidemic prevention and control. In recent years, there have been instances of countries being unable to make direct reports to Taiwan about cases of infectious diseases that had the potential to affect the country and its citizens. Taiwan’s Centers for Disease Control only received related information via secondhand sources several months after the fact, representing a gap in epidemic prevention and control.

Dr. Michael Ryan, Executive Director of the WHO Health Emergencies Programme, has made factually incorrect statements regarding the COVID-19 outbreak, saying, “We have Taiwanese experts involved in all of our consultations, clinical networks and lab networks and all those so they are fully engaged and fully aware of all the developments,” and that WHO has been “engaging with technical colleagues on the Taiwanese side over the whole course of this event … in all aspects of technical cooperation.” It should be recalled that during the SARS outbreak in 2003, dozens of Taiwanese tragically lost their lives because Taiwan was unable to access the global reporting system, or receive the most up-to-date information on cases or assistance from WHO. The international community must not allow such a painful episode to recur. The COVID-19 outbreak is a reminder to all the world, once again, that politics has barred Taiwan from contact and communication with WHO and global public health experts, and this can only gravely damage global cooperation in epidemic prevention and control. Only by including Taiwan in WHO and global cooperation mechanisms for epidemic prevention and control will it be possible to fully and effectively prevent and control epidemics, leaving no one behind.

• WHO technical meetings

In addition to its continuing efforts to attend the World Health Assembly, Taiwan actively seeks to attend technical meetings organized by WHO so as to work in line with the rest of the world and improve Taiwanese people’s health and wellbeing. However, of the 187 technical meetings Taiwan applied to attend between 2009 and 2019, only 57 applications were accepted, for a very high refusal rate of 70 percent. Other than WHO’s political considerations, China’s obstruction has been the primary reason for this. Placing politics above the right to health of Taiwan’s 23 million people in this highly improper manner is unreasonable and irrational, and contradicts WHO’s founding purpose. China has politicized Taiwan’s participation in WHO.

• Taiwan can help

Taiwan has transformed itself from a recipient of foreign aid to a provider of international humanitarian assistance, and continues to actively assist other nations in building public health capacity. According to statistics released by the crowd-sourced global database Numbeo, Taiwan received the highest ranking for Health Care Index by Country 2020, with a score of 86.71, while in 2019, CEOWORLD magazine ranked Taiwan highest in its Health Care Index. Taiwan’s development experience can serve as a valuable point of reference for many countries. In addition to guaranteeing the right to health of Taiwan’s 23 million people, bringing Taiwan into the global public health system would also yield benefits for many other countries.

• Striving to develop public health cooperation with other countries

To improve disease monitoring and emergency preparedness in the Asia-Pacific region and the wider world, Taiwan has cooperated with the US, Japan, and other like-minded nations to address such significant communicable diseases as MERS, dengue fever, Zika, chikungunya, enterovirus, and drug-resistant tuberculosis through six workshops held under our Global Cooperation and Training Framework (GCTF). To date, senior medical personnel specializing in epidemic prevention and control and lab technicians from 20 Asian and Caribbean nations have participated, establishing a cross-border network for cooperation in epidemic prevention and control. Furthermore, since its establishment in 2002, the Ministry of Health and Welfare’s Taiwan International Healthcare Training Center has assisted in the training of more than 1,600 public health personnel from 68 countries. All of these efforts prove that Taiwan is determined, willing, and able to contribute to cooperation and exchange in matters of global public health.

• Universal health coverage

With the implementation of National Health Insurance (NHI) in 1995, Taiwan achieved the objectives of universal health coverage and equal access to care. In 2019, with health expenditure at 6.3 percent of GDP, the NHI system had an 89.7 percent approval rating among Taiwanese citizens, earning recognition from the rest of the world. Responding to the advent of the age of digitization, Taiwan has actively promoted digital health, developing its MediCloud system and AI-assisted precision medical reviews. This has reduced the unnecessary duplication of medical procedures when checking on patients, raising the efficacy and quality of medical services.

• Global influenza pandemics

Taiwan formulated four strategies (surveillance and assessment; interruption of transmission; antivirals; and influenza vaccines) and five lines of defense (containment abroad; border control; community epidemic control; maintenance of medical system functions; and individual and family protection) in response to the threat of global influenza pandemics. This proved effective in combating the 2009 outbreak of H1N1, when Taiwan ranked third-lowest in mortality rate compared to OECD countries. Taiwan also successfully restricted imported cases during the 2013 outbreak of H7N9 in China, with five imported cases and no indigenous cases. Furthermore, since 2016, more than 25 percent of the Taiwanese population is now eligible for flu shots thanks to an active increase in government-funded immunization coverage.

• 2020 WHO Year of the Nurse and Midwife

WHO has declared 2020 the Year of the Nurse and Midwife. Taiwan has a policy of actively investing in related human resources; our innovative home nursing care and micro social-enterprise operating model has raised nursing capacity in the health care system, effectively increasing numbers of nursing practitioners and expanding universal healthcare coverage. Furthermore, through Maternal and Infant Health Care Improvement and other programs, Taiwan is also assisting other countries to strengthen the functions of their medical and care institutions, and provide community hygiene education for pregnant mothers and newborns.

• Chronic disease prevention

Through a chronic disease prevention framework covering primary, secondary, and tertiary prevention, Taiwan is applying holistic life-course approaches that focus on whole-body concepts of health care, actively screening for diseases and implementing early detection and early diagnosis and treatment. For example, integrating county and municipal resources to promote chronic obstructive pulmonary disease (COPD) management and an early intervention program for COPD patients is providing early diagnosis and personalized health education, as well as health care referral and tracking services, on a case-by-case basis. Furthermore, through the Capacity Building for the Prevention and Control of Chronic Disease program, Taiwan is also assisting other countries to address such chronic diseases as kidney disease and diabetes, raising community residents’ capacity to deal with such issues independently.

Legal Perspective

In 1972, the World Health Assembly (hereafter referred to as “WHA”) voted to formally recognize the People’s Republic of China replacing Taiwan as the legitimate representative of China. In 2009, Taiwan was invited to participate as an observer in the 62nd WHA as “Chinese Taipei”. In fact the Health Minister of St. Vincent and the Grenadines in his speech at the World Health Assembly in May 2019, argued as to why Taiwan should be ethically and logically included at the assembly gathering. The Hon’ble Minister emphasized the fact that Taiwan was a separate nation having an autonomous government and akin to the spirit of one Caribbean with many nations, there was no reason why also a “one China” with separate nations should not be allowed to participate. The WHA is the plenary decision-making body of the World Health Organization (hereafter referred to as “WHO”), the United Nations specialized agency for health, and the main forum through which member states discuss and adopt resolutions pertaining to the organization’s mandate. Along with member states, other entities can be granted permission to participate as non-voting observers at the WHA. There are three formally recognized subtypes of observer status: (a) non-member states; (b) representatives of the Palestinian and Occupied Territories under WHA resolution 27.37; and (c) invited observers which participate at the annual invitation of the Director General. Observer status has no legal standing under the WHO Constitution. The Taiwanese interest in seeking observer status is justified because the countries exclusion would undermine domestic public health which would be completely against the spirit of the WHO. WHA participation is hence practically important. Given Asia’s geographic proclivity to various outbreaks such as the SARS outbreak, the continued exclusion Taiwan from WHO activities may be considered as problematic, especially amid the increasing transboundary mobility of health determinants and outcomes.

Conclusion

Article 37 of the WHO Constitution stipulates that “in the performance of their duties the Director-General and the staff shall not seek or receive any instructions from any government or from any authority external to the Organization.” WHO should thus maintain a professional and neutral position, and refuse to be swayed by inappropriate political interference. Furthermore, given that Taiwan is not part of the People’s Republic of China, and that only the democratically elected government of Taiwan can represent Taiwan’s 23 million people at WHO in seeking to safeguard their right to health, WHO should explore appropriate means of implementing Taiwan’s comprehensive participation in WHO meetings, mechanisms, and activities.

Taiwan restructured its public health systems following the SARS outbreak in 2003, strengthening emergency preparedness for novel infectious diseases, and establishing better medical and epidemic prevention and control systems. We are very well placed to make a substantial contribution; the international community has widely recognized Taiwan’s achievements and capacity in public health and medicine, and more and more countries are supporting our bid to participate in WHO on the basis of professional need. Taiwan is a good partner, not a troublemaker. With the principles of professionalism, pragmatism, and making contributions in mind, Taiwan will continue to work with the rest of the world in jointly seeking the “attainment by all peoples of the highest possible level of health” as stipulated in the WHO Constitution. In turn, we hope the world will staunchly support Taiwan’s inclusion in WHO.