Chen Chien-jen, minister of the Department of Health (DOH), spent the morning of Saturday, June 21 giving a series of interviews to the media. For the first time in several months, Chen was able to breathe more easily, because four days earlier the World Health Organization had lifted its advisory against travel to Taiwan.

After graduating with a B.Sc. from the Department of Zoology and an MA in Public Health from National Taiwan University (NTU), Chen obtained a doctorate in epidemiology and human genetics from John Hopkins University in Baltimore, Maryland, in 1982. Soon after returning to Taiwan, he made a name for himself in the medical community with his discovery that blackfoot disease, a peripheral vascular disorder endemic to the southwest coast of the island, was caused by the consumption of artesian well water containing high levels of arsenic. But in 1989, while Chen was an associate research fellow at the Academia Sinica's Institute of Biomedical Sciences, it was noted in his annual assessment that he was "a long way from becoming a scholar of international standing." This wake-up call prompted Chen to apply for a research fellowship at Columbia University's School of Public Health. In 1993, Chen was named fellow at the American College of Epidemiology, and in 1998, aged 47, he was appointed academician in the Division of Life Sciences at the Academia Sinica.

Modest and good-natured, Chen Chien-jen is also an effective communicator. In mid-March, he took on the responsibility of convening the SARS Contingency Committee set up by the Executive Yuan. On May 17, when the epidemic was at its height, Chen jumped into the breach and assumed the post of minister of the DOH. In this interview Chen reveals that one of his biggest challenges as the first DOH head without a background in medical practice is how to confront the Taiwanese healthcare system's greater emphasis on treating and curing illnesses than on preventing them.

Q: Given the considerable success achieved 30 years ago by Taiwan's public health system in eradicating smallpox, cholera, malaria, polio, and other infectious diseases, why has this experience not been put to good use during the SARS epidemic? What shortcomings in the Taiwanese healthcare system have emerged from the battle against SARS?

A: After Taiwan was liberated from the Japanese in 1945, the Taiwanese public healthcare system was reformed. At the time, the Joint Commission for Rural Reconstruction received American economic assistance. Under the leadership of Hsu Shih-chu, director of the Commission's public health department, and Yen Chun-hui, director of the Taiwan Provincial Government's Health Department, these funds were used to establish a basic sanitation and public health framework comprising health centers, clinics, public toilets, running water, preventive vaccination, and better hygiene for women and children.

At that time, the United States also provided aid to the Philippines, which used it to build a modern hospital in Manila. Thirty years later, the Taiwanese enjoy a far higher average life expectancy and better health than the people of the Philippines. The reason is that after the war we spent most of the aid money on a basic healthcare infrastructure and on ordinary people to prevent the spread of disease and improve public health, rather than on high tech medical equipment and treatment facilities. Interestingly enough, in those days wealthy Taiwanese who suffered from ischemic heart disease, apoplexy, or other serious disorders would rush to the Philippines for treatment.

Disease prevention and treatment follows three stages: first comes the promotion of health; then, early diagnosis and effective treatment; and last, the reduction of disabilities and rehabilitation. The first two stages are preventive. Because everyone benefited from the fruits of the Taiwanese public health system three decades ago, little thought was given to continuing the work in the years that followed. Moreover, as chronic illness has replaced infectious disease as the greatest menace to public health, hospitals have grown in size and number, medical technology has advanced, the number of students in medical school has shot up, the practice of medicine has become more specialized, hospitals have been forced to acquire the latest medical equipment, and patients have become much more numerous. Large hospitals have come to resemble crowded vegetable markets, with patients flocking to them with ailments big and small. Upwards of 10,000 outpatient consultations per day is the norm in such hospitals. The situation in remote rural areas, on the other hand, is very different. In rural areas, Aboriginal villages tend to fare the worst, lacking the most basic medical resources.

Hospitals that overemphasize cost effectiveness and doctors, nurses, and medical technicians that seek to streamline personnel management make patients spend more time registering, sitting in waiting rooms, and obtaining medication than being examined and diagnosed by physicians. The fact is that doctors who examine symptoms without looking into the cause of diseases take a big risk. The SARS epidemic has shown that simply prescribing an antipyretic to a patient running a fever is pointless. Instead, physicians need to conduct transdisciplinary pathogenic analyses comprising tests on bacterial cultures, blood serum, blood samples, and the like.

To save on personnel costs, hospitals outsource cleaning and laundry services and employ fewer nursing staff. Consequently, patients are looked after by healthcare assistants who move from room to room and hospital to hospital. Under such circumstances, infection foci are difficult to locate and contain. Clearly, our hospitals have come to be managed according to corporate principles that stress profit more than genuine care, and competition more than equal treatment for all.

Q: A WHO study has concluded that Taiwan's problem in combating the epidemic resides not in medical science but rather in the inability of various government and health agencies to coordinate their work. What measures can be taken to improve this situation?

A: SARS has highlighted the problem of insufficient integration and coordination. By April 15, we only had 20 reported SARS cases, 90% of whom were people who had brought the disease from abroad. The SARS outbreak within the Taipei Municipal Hoping Hospital on April 24 greatly increased the hospital's need for medical supplies. Whereas previously we needed only 50,000 industrial-level N95 protection masks a year, we now use 100,000 masks every day, 700 times as many as before. The entire world is buying up N95 masks and protective clothing, leading to a serious shortage. There is not much the DOH can do other than to ask the Ministry of Economic Affairs for assistance. Moreover, because there is a lot of travel between Taiwan and mainland China, when 10,000 people were quarantined recently, the Mainland Affairs Council and the Ministry of the Interior inevitably became an integral part of the anti-epidemic system.

Coordination between various government and medical agencies is difficult. In the first three weeks of SARS, we faced too many difficulties to cope with, because SARS was an enemy about which we knew next to nothing. Mistakes were inevitable when meeting the disease head-on. Fortunately, the epidemic began to abate as coordination between various central and local government authorities and between hospitals and clinics became more effective.

Fighting an epidemic is like waging war: it requires horizontal coordination. Private and public hospitals must plan in advance which roles each will play the day biochemical war breaks out. As Sun Zi put it in The Art of War, "Do not depend on the enemy not coming; depend rather on being ready for him."

WHO experts assisted us in devising standard operating procedures and in inspecting the management and control measures in place in 17 major teaching hospitals, including staff training, protective equipment, proper setup of negative pressure rooms, transportation of patients, and so forth. The teaching hospitals then inspected 69 regional hospitals, which, in turn, inspected 400 local hospitals. In this way, hundreds of hospitals throughout Taiwan were inspected in less than three weeks.

Despite these thorough inspections, an outbreak occurred inside Taipei's Yangming Hospital. The Achilles' heel in the system was that our healthcare assistants and cleaning staff were not employed by the hospital and were able to move freely from one room to another and even from one hospital to another. They posed a greater threat as carriers than actual hospital staff, but even the foreign experts failed to recognize this, because the system of ambulatory healthcare assistants and cleaning staff is particular to Taiwan. As we began to look into it, we discovered a large number of Achilles' heels, or blind spots, in the prevention of epidemics. The American experts thanked us for the information we provided them. Should an outbreak occur in New York, similar problems might be encountered, because the city has a large number of homeless people, prostitutes, and transients. Taiwan's baptism by fire has strengthened its system of epidemic prevention and control and has provided experience that will prove invaluable to countries around the world.

Q: According to official statistics, 90% of Taiwan's healthcare budget is spent on hospitals and only 3% on public health. How can this disparity in the use of resources be reversed?

A: In mid-June, I asked four experts to conduct a multidisciplinary general survey of Taiwan's public health and medical system: Yeh Chin-chuan, former head of the Bureau of National Health Insurance, examined Taiwan's health insurance system; professor Hsieh Po-sen of National Taiwan University's Department of Public Health examined the healthcare system, basic healthcare, and hospital administration; Wang Te-jung, Dean of NTU's College of Public Health, examined the workings of the Taiwan Center for Disease Control and the DOH's Bureau of Health Promotion; and professor Huang Po-chao of NTU's College of Medicine examined Taiwan's food and drug administration. We will bring out a blueprint for improvement at October's National Healthcare Congress.

In the future, public health clinics in remote rural and Aboriginal areas will continue to play a role in the treatment of disease, but the main emphasis will be on breathing new life into their preventive medicine, public health, community healthcare, and health promotion services. We will strengthen clinics' IT and computer resources to monitor and manage community health. Doctors opening a practice will be given responsibility for local healthcare, including keeping good medical records and sending patients who really need it to a hospital. Without such a system, I'm afraid that we won't be able to cope well with infectious diseases such as SARS or even with chronic illnesses.

My hope is that expenditure on medical care and public health will be redistributed to 70% and 30%, respectively. After all, hospitals need lots of expensive equipment and have higher outlays than public health programs, which offer more bang for your buck. But although expenditures can be adjusted, the effectiveness of public health prevention measures is difficult to determine with any degree of precision. Many people ask whether prevention really works. In 1996 the Department of Health began to conduct computer-aided statistical analyses of Pap smear tests. Within six years, there was a marked drop in the death rate from cervical cancer, a fact we can cite to tell people that good public health prevention is genuinely effective.

A basic principle of epidemiology is that the prevalence rate equals the incidence rate multiplied by the duration. Previously, someone who contracted diabetes had a life expectancy of only five years, and the prevalence rate wasn't high. Today, diabetes sufferers survive more than 20 years, which is equivalent to a fourfold prevalence-rate increase. Because medical advancements have lengthened the life expectancy for sufferers of such diseases, ever more patients are in need of care. The only way to cope with constantly rising healthcare costs is to lower the disease incidence rate. We currently rely on health insurance to buy medical treatment. What people don't like to hear is that they are paying to prolong a life of sickness rather than health and a good quality of life. If only ordinary people understood this, a complete reform the medical and public health system would be possible.

Q: The SARS epidemic seems to have subsided, but since, as is widely acknowledged, the Taiwanese people have a short memory, how well will we be prepared if the epidemic stages a comeback this coming fall and winter?

A: I'm also worried about this. At a conference in Kuala Lumpur in June, the WHO was concerned about various factors in its campaign to eradicate SARS: first, we still don't know whether patients with a light infection whose symptoms are not apparent can transmit the virus directly, nor whether such patients can be quarantined effectively. Second, it has still not been proven whether in addition to person-to-person transmission, there are animal infectious agents. We have to proceed with great caution: if it turns out that wild animals harbor the virus, it will make it much harder to eradicate SARS. Lastly, what's happening in mainland China is far from clear: the authorities can transfer hordes of SARS patients to the outskirts and claim that the capital is free of the disease.

As long as the mainland, Hong Kong, and Taiwan continue to be in such close contact, that is to say, as long as 10,000 people on average continue to travel across the Taiwan Strait in a single day, eliminating SARS will prove to be exceedingly difficult. Will there be another outbreak? Asian leaders are very concerned and in Hong Kong they are downright scared. At the meeting in Kuala Lumpur, the Hong Kong representative said that people in his city hoped that all countries would be more transparent in reporting the epidemic, because hundreds of thousands of mainlanders pass through Hong Kong's Hung Hom railroad station every day and many of them are commuters. Hong Kong is scared by such a situation, though they don't dare admit to it openly.

SARS is a big test of the transparency of information in mainland China, Hong Kong, and Taiwan, as well as of people's honesty. Some SARS patients go from hospital A to hospital B but don't dare admit it. In Taiwan, the IC health insurance card, which was introduced in July for use in hospitals, allows us to see people's medical records at a glance, greatly facilitating SARS prevention.

Moreover, should the epidemic strike again this coming fall or winter, we won't disperse patients across more than 100 hospitals, but will confine them to 14 hospitals specializing in SARS treatment. We currently have 700 hospital beds in negative pressure rooms. Given our shortage of infectious disease specialists, we can second specialists from 17 major teaching hospitals to provide assistance in these 14 hospitals. But to prevent another outbreak in a hospital, we certainly have to do a better job of monitoring fever and separating potential SARS patients from other patients.

This fall and winter, influenza and SARS could be confused. Until recently, flu vaccinations were focused on people 65 and older. This September we could launch an early universal flu vaccination program aimed at rapidly distinguishing SARS from flu symptoms. Flu vaccinations would thus become an effective differentiation tool, with high-risk groups such as the elderly, medical personnel, and hospital patients in the vanguard.

According to independent estimates, the SARS epidemic caused economic damage totaling NT$50 billion in Taiwan. If we spend even NT$100 million on preventive inoculations, we could save well over NT$40 billion.

Q: Now that summer is here, what measures are being taken to guard against viruses other than SARS, such as the enterovirus and dengue viruses?

A: One of the effects of SARS is that people now routinely wash their hands and take their temperature. It is to be hoped that these habits will be internalized by all citizens in their daily life: as soon as you develop a cough or run a fever, you put on a face mask to protect yourself and others. And whenever you eat something, you wash your hands beforehand, because doing so prevents enterovirus infection.

Regarding dengue fever, the Environmental Protection Administration is already working closely with us. Areas with a high incidence of vector mosquitoes are immediately targeted for disinfection. Wherever a case of dengue fever is reported, the EPA quickly dispatches a team to carry out indoor and outdoor disinfection. As long as public health workers and doctors on the frontline of the disease are quick to report cases to the EPA and the Department of Health, we will establish an effective environmental and public health network.

Enterovirus and dengue fever can be prevented by means of sound public health measures. But most recently, a breach occurred in the prevention of Japanese encephalitis. Because many parents were afraid of going to hospital, they failed to take their children to be vaccinated. We responded straight away by asking clinics in all localities to find out whether parents had sent their children to get booster shots and to urge them to do so if they hadn't.

Q: What lessons should the global community draw from SARS?

A: All too many previously unknown infectious diseases appeared during the twentieth century. All of them, including swine flu and avian influenza, jumped from wild animals to human beings. Humankind clearly did something wrong: we invaded wild animals' habitats, allowing many animal-borne pathogens that did not cause disease in animals to wreak havoc in human populations. Such diseases include Aids, ebola, hanta fever, yellow fever, malaria, and so forth.

The civilization of which humankind is so proud has produced global warming and El Nino, and has extended the territorial scope of disease vectors, including the malaria and dengue mosquitoes, from the tropics to temperate zones. If our relationship with nature is to be harmonious, as it must, we will have to return to a life of diligence and frugality. If we continue to think that man must conquer nature, we will face a never-ending plague of new infectious diseases.

Introduced on July 1, the IC health insurance card helps to track patients' medical records and will help in the fight against infectious diseases.

Committed to the principle that prevention is more important than treatment, hospitals are keeping their temperature checkpoints going.

Taiwanese people have plenty of reasons to celebrate, but they must not forget what it cost to win this battle against SARS. The epidemic may have been defeated for the time being, but humankind's battle against infectious disease is unending. The photo shows prayers for good luck suspended from a tree in a housing complex in Taipei City that was quarantined during the SARS epidemic.