The challenges that COVID-19 poses for governments around the world are formidable. For Taiwan, there have been additional hurdles.
Experts say the island's response to the novel coronavirus has been remarkably effective so far, despite many serious challenges, starting with its close links to China,and may even hold lessons for others to follow.
"Taiwan is sort of a positive deviant," said Jason Wang, a pediatrician who heads the Center for Policy, Outcomes and Prevention at the Stanford University medical school.
"It did really well when they were not expected to do so well."
As of Friday, Taiwan has reported 50 confirmed cases of coronavirus, and one death, out of a population of around 23 million.
The island has seen a relatively low spread of the novel coronavirus despite its proximity and numerous links to China, where the virus was first detected and has infected more than 80,000 people. Taiwan has also had to contend with political pressure and possible misinformation from China.
In a paper this month in the Journal of the American Medical Association, or JAMA, Wang and two colleagues listed 124 actions that Taiwan's authorities took starting in December when they sensed the looming threat — and the rest of the world seemed to be looking the other way.
Taiwan quickly launched and updated emergency measures as the outbreak grew in China's Hubei province and then spread. Taiwan activated a response command center, sent a fact-finding team to China, imposed swift travel bans and quarantines. It even restricted the export of face masks.
Taiwan's health-care system ranks among the best in the world. And it learned lessons from the experience of SARS 17 years ago, when it was the third worst hit territory after China and Hong Kong.
"They had basically prepared for the next crisis because after SARS people were so just shocked by the impact both to the people and the economy," Wang said.
The "importation risk" for coronavirus was real for Taiwan.
Millions of people travel back and forth between China and the island each year. Last year, there were more than 5,700 flights per month, on average, between Taiwan and the mainland, according to Taiwan's Ministry of Transportation and Communications. Nearly 11 million passenger journeys were made across the narrow Taiwan Strait by plane.
When the number of coronavirus cases started to spike in China in January, a study by Johns Hopkins University ranked Taiwan as one of the most at-risk locations.
'Marginalize and exclude'
Proximity to China was only part of the challenge.
Beijing considers the self-ruled, democratic island a part of China and has vowed to unite it eventually with the mainland, by force if necessary.
On the global stage, the Chinese government has tried to squeeze Taiwan.The island only has a handful of diplomatic allies, and it's not a member of the United Nations or the World Health Organization.
That has real-life implications during a disease outbreak, according to Richard Bush, a senior fellow at the Brookings Institution.
"Practically speaking, it means that certain types of information that WHO members get as a matter of course are not available to Taiwan — even though it does have cases, even though it has something to contribute when it comes to understanding and monitoring this disease," he said.
The problem has been exacerbated by China's distrust of Taiwan's president, Tsai Ing-wen, whose Democratic Progressive Party has traditionally leaned toward independence for the island — a red line for Beijing.
Tsai's predecessor, Ma Ying-jeou, was widely seen as more China-friendly, and the authorities in Beijing dangled more carrots in front of Taiwan during his administration. On the health front, Taiwan was allowed to attend the annual gathering of WHO members as an observer from 2009 to 2016 when he was president.
"Particularly because China doesn't like the current president of Taiwan, Tsai Ing-wen, it is working particularly hard to marginalize and exclude it from all international governmental organizations in spite of the circumstances," Bush said.
Taiwan hasn't been completely boxed out during the coronavirus outbreak.
The WHO says it has been in communication with Taiwan on a technical level, although a spokesman declined to provide details when asked by NPR.
Taiwan's government declined to comment on the challenges of tackling COVID-19 as a nonmember of the WHO.
In early February, Taiwanese scientists were allowed to attend — by videoconference — part of a WHO forum in Geneva on the coronavirus.
Rumors and "nonsense"
An additional challenge also emerged for Taiwan: disinformation.
As the virus spread in China in late January, a stream of rumors and fake news about Taiwan's response to the outbreak began to appear on social media sites, including Facebook and Twitter, according to researchers who track the issue.
One of the first claimed that the outbreak was out of control in southern Taiwan and that trucks were being used to haul bodies to crematoriums, according to Summer Chen, editor-in-chief of Taiwan FactCheck Center, a group that ferrets out and debunks dodgy reports.
"At the time, the news looked to me like nonsense, or something that you'd never believe," said Chen.
More reports followed.
A proliferation of misinformation in the runup to the presidential election on Jan. 11 helped raise awareness of the problem among the people of Taiwan, who Chen says are getting better at identifying and dealing with problematic online posts.
"I think most Taiwan people who read them would think they're funny or fun, but when information is in large quantities, especially with society on alert already, I think it's very malicious," she said.
It's unclear exactly who is behind the latest misinformation, but linguistic clues point to China, Chen and other researchers say.
Some of the posts used simplified Chinese characters or terminology that's common on the mainland but not in Taiwan.
Nick Monaco, research director of the Digital Intelligence Lab at Institute for the Future, has analyzed many of the posts and says they appear to have come from "normal users online in China," rather than the state.
But, he adds, the Chinese government has the ability to stop them — and it hasn't.
"Disinformation campaigns online about coronavirus targeting Taiwan and targeting other countries, they are being permitted to ... jump over the 'Great Firewall' and kind of propagate online, and I think that is very malicious," Monaco said.
Neither China's Foreign Ministry nor the information office of the State Council, or cabinet, had an immediate comment when NPR faxed them questions about the online activity and Taiwan's exclusion from the WHO.
The net effect of Taiwan's non-membership in the World Health Organization and the spread of virus-related disinformation targeting the island is hard to measure. But the risk of a wider spread of the virus is undoubtedly elevated, experts say.
"When you have an environment of restricted information on top of all those degrees of misinformation it makes decision-making difficult — both as an individual and as a government," said Heidi Larson, who researches disinformation and vaccines at the London School of Hygiene & Tropical Medicine.
But against the odds, Taiwan has kept COVID-19 in check so far.
Stanford's Wang and his colleagues will continue to track how Taiwan fares.
"We're still in the middle of it. Probably it will take six months before we fully know," he said.
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