Lessons from 2003 SARS in Taiwan - decisions against threat matter

Taiwan achieved 253 consecutive days of zero domestic cases in 2020 under the COVID-19 pandemic. People generally attributed such success to its SARS experiences. However, after Taiwan shifted to a living-with-the-virus model in 2022, it experienced a similar Omicron epidemic as the rest of the world. This chapter provides the history of the 2003 SARS outbreak in Taiwan according to the four stages of a shock cycle and the four domains of health system function. In addition to sharing the adaptations and support applied to maintain, restore or improve the health system resilience, key decisions in governance which might have changed the development/impact of the outbreak are highlighted. The main lessons learned and thus applied to COVID-19 responses, which made Taiwan a champion during 2020-2021, are summarized. Drawing on these facts, the author questions whether it is the health system preparedness (such as the health system capacity improved after previous outbreaks) or the decision on the strategy (such as the containment/elimination strategy vs. the living-with-the-virus strategy) against the threat that makes the greatest difference in the consequences. To avoid another devastating global impact from the next novel infectious disease, what should be considered before it is too late? The zero-COVID multi-level containment design based on SARS experiences, lessons for future outbreaks and insight on determinants of health system resilience are provided.