When they heard about patients falling sick with a mysterious pneumonia in the Chinese city of Wuhan on Dec. 31, Taiwan’s health officials fired off an email to the World Health Organization asking for more information.
This four-sentence inquiry has since become fodder for the political brawl between China and the U.S. and threatens to bruise the reputation of the U.N.’s health agency as it leads the fight against an unprecedented global pandemic.
Taiwanese and U.S. officials have seized on the email to argue the WHO ignored an early warning that the coronavirus could likely be transmitted between people. In the weeks following the Dec. 31 note, the WHO echoed Chinese officials that there was “no clear evidence of human-to-human transmission”— even as cases began cropping up that raised suspicion of contagion.
In an interview with TIME, Dr. Lo Yi-chun, the deputy director-general of Taiwan’s Centers for Disease Control (CDC), says the WHO should have acted on Taiwan’s query by conducting its own investigation. Instead, he says the WHO “provided a false sense of security to the world.”
The WHO has defended its handling of the outbreak and says it relies on member countries like China to accurately report their findings. It also notes that Taiwan’s email did not explicitly mention human-to-human transmission, and that the self-governing island was not the first nor the only one to contact the organization about the disease.
Yet the scrutiny has intensified. President Donald Trump — facing criticism over his own government’s response — has cited Taiwan’s email as evidence of the WHO allegedly helping China coverup the severity of the outbreak, and suspended U.S. contributions to the health agency in April. Both Beijing and the WHO deny any concealment.
On Tuesday, Trump threatened to make the funding freeze permanent in a letter sent to the WHO leader as nations gathered virtually for the WHO’s annual decision-making meeting. Referencing “repeated missteps” in the WHO’s steering of the pandemic response — including choosing “not to share” Taiwan’s communication — Trump said he could no longer commit American taxpayers’ dollars to the agency unless it undertakes “major substantive improvements in the next 30 days.”
With Taiwan in the spotlight, TIME spoke with health officials, politicians and analysts to unpack what the island of 23 million knew in the critical early days of the pandemic when it initiated a quick response that helped it keep its infection rate among the lowest in the world.
At 6:30 a.m. on Dec. 31, Dr. Lo at Taiwan’s CDC woke to an alert on his phone.
His colleagues in the media monitoring unit had detected social media posts about a pneumonia of unknown cause in Wuhan. The original posts in China were quickly removed, but screenshots had been reposted on PTT, a popular online forum in Taiwan. Some commenters feared a resurgence of the Severe Acute Respiratory Syndrome (SARS), which had killed 774 people in 2002 and 2003, mostly in Asia.
Lo, an infectious disease expert, looked at the images of laboratory reports and doctors’ messages and suspected something else, something new. “But whether the source was reliable or … indicated the correct pathogen [couldn’t] be proved just from reading that,” he says. So he instructed his colleague to get in touch with counterparts in Beijing and the WHO through the International Health Regulations mechanism, a WHO framework of exchange between countries, to ask for more information.
Around 1:30 p.m. that afternoon, the Wuhan Municipal Health Commission announced 27 cases of pneumonia related to a seafood market. It said their investigations found “no clear human-to-human transmission.” It would be another three weeks before a top Chinese government-appointed expert would confirm on state TV that the disease could spread between people, followed two days later by a WHO statement that said data “suggests that human-to-human transmission is taking place in Wuhan.”
But Taiwan didn’t wait to step up precautions. On Dec. 31, the island began instituting health screenings for all flights arriving from Wuhan. “We were not able to get satisfactory answers either from the WHO or from the Chinese CDC, and we got nervous and we started doing our preparation,” Foreign Minister Joseph Wu tells TIME.
A matter of interpretation
It took time, but that email Lo instructed his colleagues to send to the WHO eventually kicked up a geopolitical storm. In March, Taiwan’s Vice President Chen Chien-jen, an epidemiologist-turned-politician, told the Financial Times the WHO had failed to relay the island’s early warning that the disease could be transmitted between people. The U.S. State Department took up the claim and said by not passing this vital information on to member states the WHO “chose politics over public health.”
Why did the W.H.O. Ignore an email from Taiwanese health officials in late December alerting them to the possibility that CoronaVirus could be transmitted between humans? Why did the W.H.O. make several claims about the CoronaVirus that ere either inaccurate or misleading….
— Donald J. Trump (@realDonaldTrump) April 17, 2020
Taiwan doesn’t have a seat at the WHO due to objections from Beijing, which claims sovereignty over the island. This exclusion, Taiwan says, is dangerous for public health. The WHO, which is governed by its member states and so does not have authority over membership, says it has been sharing information related to the pandemic with Taiwan. Meanwhile, the Trump Administration has homed in on the status of its ally as it attacks the relationship between the WHO and China.
With the row escalating, and after WHO chief Tedros Adhanom Ghebreyesus accused Taiwan of backing a racist campaign against him, the island’s CDC publicly released its Dec. 31 email.
Written in English, the text mentions reports of “at least seven atypical pneumonia cases” and notes that patients were being “isolated for treatment.” Taiwan’s foreign ministry tells TIME in an emailed statement that this precaution was the smoking gun, “strongly suggesting that there was a possibility of human-to-human transmission,” since it would not have been necessary if the disease was not infectious. Public health officials could have discerned from this wording an implied warning about contagion, according to statements from Taiwan’s foreign ministry and CDC.
Health experts contacted by TIME were divided, with some noting that “atypical pneumonia is assumed to be communicable,” while others say isolating patients with a potentially novel pathogen is a sensible precaution.
A man holds a Taiwan flag as passengers disembark from the Diamond Princess cruise ship due to fears of COVID-19 in Yokohama, Japan on Feb. 21, 2020. | Philip Fong—AFP/Getty Images
For its part, the WHO denies ignoring a warning from Taiwan. Spokesperson Tarik Jasarevic says the WHO received Taiwan’s email only after Wuhan’s announcement about the outbreak. The inquiry, he adds, made no mention of human-to-human transmission, but was nevertheless forwarded to experts collating information on the outbreak.
According to Tedros, Taiwan was also not the first to flag what was happening in Wuhan. “Many other countries were already asking for clarification,” he said.
WHO spokesperson Paul Garwood tells TIME that on Dec. 31, “a health authority from a regional bloc of countries” and another country also flagged the outbreak and requested information, though they did not warn about human-to-human transmission. Garwood says he could not publicly reveal who they were because such communications are confidential.
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As the full extent of the outbreak came into focus, a growing chorus of government officials, health experts, editorial boards and academics began scrutinizing the WHO, and accused it of being too deferential to Beijing.
In Japan, deputy prime minister Taro Aso noted in March that people are referring to the organization as the “Chinese Health Organization” due to what he described as its links to Beijing. In Washington, seven Republican Senators are calling for an investigation into the WHO’s handling of the crisis and whether China manipulated the organization. Over 1 million people signed a petition calling for Tedros to resign.
That the information put out by the WHO “coincides exactly” with the Chinese government’s position “does raise very serious questions as to whether the WHO has been exceptionally focused on accommodating the wishes of a particular member state, namely China,” says Steve Tsang, director of the SOAS China Institute at the University of London.
Leading health academics have suggested that the WHO created a false sense of reassurance by continuing to commend Beijing’s “transparency,” despite the reports of possible undercounting, and of Wuhan officials’ punishing doctors who had warned about the virus. During the SARS crisis, the WHO had publicly criticized Beijing for trying to conceal the outbreak.
A WHO spokesperson said the responsibility for reporting truthful information rests on member states. “WHO expects all its member states to report data in a timely and accurate manner,” says Jasarevic. The agency aims to “keep open lines of communication” in the midst of a crisis, he says. “Publicly calling out mistakes does not help.”
A member of the WHO’s own emergency committee, John Mackenzie, said that international action would have been different if not for Beijing’s “reprehensible” response to the coronavirus and underreporting of cases early on. Others laid the blame on the WHO, insisting it could have been less credulous of the information coming out of China and sounded alarms about contagion earlier.
“It would have made a hell of a difference,” says François Godement, senior adviser for Asia at the Institut Montaigne, a nonprofit group in Paris. “In many countries there was complacency about the contagiousness of the virus,” he says, adding that in France, medical authorities maintained for weeks that there was no proven risk of human-to-human spread in part because the WHO had reiterated China’s claims that there wasn’t.
Even Taiwan, which is generally wary of information provided by Beijing, was still “fifty percent trusting,” says Lo at Taiwan’s CDC. “Because it was released not only by China, but also adopted by WHO, we believed there must have been some verification that was done.” Instead, he says, the WHO was acting as China’s “photocopying machine.”
Asked about the allegation, WHO spokesperson Jasarevic says, “We use and analyze data provided by countries.”
Godement says that China’s influence has grown across the whole U.N. system because of the second-biggest economy’s rising mandatory contributions, its role on budgetary committees and because U.N. institutions have “great expectations that China will contribute more.”
Stéphane Dujarric, a spokesperson for the U.N. Secretary-General, says, “The United Nations is made up of sovereign member states. For the U.N. to function, it’s important all member states participate actively in its work.”
The WHO has repeatedly responded to criticism that it is too deferential to China and too slow to flag the possibility of the virus’ contagion. “With any new virus, especially a respiratory pathogen, the first and most obvious question we ask is whether human-to-human transmission is occurring. That’s epidemiology 101,” says Gabriella Stern, the WHO’s director of communications.
Stern pointed to guidance issued by the WHO on Jan. 10 and 11, which indicated more information was needed about the virus’ mode of transmission and offered interim guidance based on knowledge of other coronaviruses, including SARS and MERS.
On Jan. 14, a WHO epidemiologist warned about the possibility of “limited” human-to-human transmission as cases popped up with no connection to the seafood market where the virus was thought to have originated. But later the same day, the organization appeared to backtrack, and said there was “no clear evidence” of such transmission.
Those familiar with the inner workings of the WHO say the health body has to weigh information from all manner of sources, including government data, WHO field offices, academic institutions, NGOs and the media. “It is hardly true that WHO simply repeats information that the Chinese government, or any government, reports to the organization,” says Kelley Lee, a professor of global health governance at Simon Fraser University who co-established the WHO Collaborating Center on Global Change and Health.
“In global epidemic intelligence surveillance, nothing is taken at face value. At the same time, it is true that the nature and quality of information about outbreaks regarding different countries still varies substantially for a range of reasons,” she says, including hesitancy of governments to share information and information not yet known.
The trip that changed everything
For Taiwan, precedent fueled its skepticism. The island suffered badly during the SARS outbreak that Chinese authorities had initially tried to coverup. So when another unknown pneumonia emerged, health officials jumped into action.
Less than 100 miles from mainland China, Taiwan was was expected to have one of the highest virus caseloads. Yet the island, which is about the size of Maryland with the population of Australia, has recorded just 440 cases and kept deaths in the single digits.
Two Taiwanese clinicians, along with experts from Hong Kong and Macau, were on one of the first fact-finding teams to visit Wuhan. The Jan. 13-15 trip coincided with a Communist Party conclave, during which Wuhan officials announced no new cases each day. This lack of reported infections and the closure of the seafood market where the virus was thought to have emerged prompted many to believe the outbreak would soon be over. But the visitors stumbled onto information that burst such optimism.
Dr Chuang Yin-ching, commander of Taiwan’s Communicable Disease Control Medical Network, and one of the experts on the trip, tells TIME he suspected the officials were “trying to hide something” because when repeatedly asked about transmissibility the answer was always unclear.
Finally, he says an official admitted there were two family clusters among the confirmed cases, one involving a husband and his physically disabled wife. “The possibility of his wife [going] to the seafood market is zero so we can pretty much be sure that the husband transmitted it to his wife,” says Chuang. That knowledge was a game-changer.
The day the experts returned, Wuhan put out a statement acknowledging “limited human-to-human transmission” was possible, but said no community outbreak had occurred.
The Taiwanese CDC, via the government press division, said that it shared a “brief summary” of the mission with “like-minded countries,” but declined to reveal which ones. When asked if the U.S. was informed, a Taiwanese spokesperson would not specify, saying, “It would not be convenient to provide such information” to TIME. A U.S. State Department official declined to comment on the details of private conversations.
A blessing in disguise
Soon after the fact-finding team returned, Taiwan activated its Central Epidemic Command Center to coordinate an outbreak response. That was three days before Wuhan was locked down. Apprehensive about the information coming out of China, Taiwan remained hyper-vigilant, Lo says.
“That helped us to safeguard our people from being affected by the first wave of [the] epidemic … otherwise we could have become Italy, or we could have become South Korea during that time,” he says.
Ironically, Taiwan’s exclusion from the WHO may have been a blessing in disguise, according to Lo.
From 2009 until 2016 Taiwan was allowed to attend World Health Assembly meetings as an observer under the name “Chinese Taipei.” But the status ended shortly after President Tsai Ing-wen came to office promoting more distant relations with China, and as Beijing took an increasingly assertive stance on the world stage.
A pro-Taiwan protester holds a flag outside of the United Nations offices on the opening day of the World Health Organization’s annual meeting in Geneva on May 22, 2017. | Fabrice Coffrini—AFP/Getty Images
The WHO says it is continuing to facilitate interactions between its experts and Taiwan despite the island’s non-member status. These include having Taiwanese health experts participate in two WHO COVID-19 networks set up in January and holding phone briefings between the WHO and health authorities in Taipei.
Still, Lo says, by not having full membership status Taiwan “kept thinking, well, we must have missed important information. That actually gave us that urgency and anxiety that we should be protecting ourselves much better by searching all the necessary social media … and not just rely on WHO’s goodwill or other countries’ goodwill to share information with us,” he adds.
Taiwan has been tirelessly trying to drum up international support amid the global pandemic, including pressing its longstanding campaign to be allowed back into the WHO. In March, Trump signed the TAIPEI Act requiring Washington to advocate Taiwan’s inclusion in international bodies like the WHO, a move poised to further destabilize U.S.-China relations.
The Trump Administration had also advocated for Taiwan’s inclusion as WHO member states convened this week for the first World Health Assembly since the coronavirus pandemic. Just before the meeting began Monday, Taiwan agreed to have its bid for participation deliberated later, citing the need for the event to focus on combatting the outbreak.
“We still need WHO,” says Lo. “And we need WHO to be stronger.”