Taiwan is 81 miles off the coast of mainland China and was expected to have the second highest number of cases of coronavirus disease 2019 (COVID-19) due to its proximity to and number of flights between China. The country has 23 million citizens of which 850 000 reside in and 404 000 work in China. In 2019, 2.71 million visitors from the mainland traveled to Taiwan. As such, Taiwan has been on constant alert and ready to act on epidemics arising from China ever since the severe acute respiratory syndrome (SARS) epidemic in 2003. Given the continual spread of COVID-19 around the world, understanding the action items that were implemented quickly in Taiwan and assessing the effectiveness of these actions in preventing a large-scale epidemic may be instructive for other countries.

Controversies over diagnostic testing have dominated US headlines about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus responsible for coronavirus disease 2019 (COVID-19). Technical challenges with the first test developed by the Centers for Disease Control and Prevention (CDC) left the nation with minimal diagnostic capacity during the first few weeks of the epidemic. The CDC also initially limited access to testing to a narrow group of individuals with known exposure. The delayed discovery of a case of COVID-19 in California, followed quickly by evidence of community transmission in multiple states, revealed the shortcomings of this strategy. In the early stages, COVID-19 has spread beyond the nation’s ability to detect it.

Pharmacy benefit managers (PBM) are important intermediaries in the pharmaceutical supply chain in the US. Under the general umbrella of administering outpatient prescription drug benefits for health plans, PBMs took on a variety of roles, including managing the drug formulary, negotiating with drug manufacturers and retailers, and processing drug claims. PBMs have come under scrutiny as we have learned more about the scale of prescription drug rebates and other payments between manufacturers and intermediaries in the prescription drug market. A lingering question is the underlying value of PBMs for payers and for patients.

Covid-19 has exposed major weaknesses in the United States’ federalist system of public health governance, which divides powers among the federal, state, and local governments. SARS-CoV-2 is exactly the type of infectious disease for which federal public health powers and emergencies were conceived: it is highly transmissible, crosses borders efficiently, and threatens our national infrastructure and economy. Its prevalence varies around the country, with states such as Washington, California, and New York hit particularly hard, but cases are mounting nationwide with appalling velocity. Strong, decisive national action is therefore imperative.

Urgent responses to the Covid-19 pandemic have halted movement and work and dramatically changed daily routines for much of the world’s population. In the United States, many states and localities have ordered or urged residents to stay home when able and to practice physical distancing when not. Meanwhile, unemployment is surging, schools are closed, and businesses have been shuttered. Resistance to drastic disease-control measures is already evident. Rising infection rates and mortality, coupled with scientific uncertainty about Covid-19, should keep resentment at bay — for a while. But the status quo isn’t sustainable for months on end; public unrest will eventually become too great.

As the coronavirus disease 2019 (COVID-19) crisis enters its next phase, attention turns to the widespread testing programs needed to resume and maintain normal life activities. Effective prevention and surveillance require testing for active infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and for antibodies that indicate prior infection and potential immunity. There is an established approach for infected individuals: mild cases self-isolate; and severe cases receive treatment. But what is the appropriate response for people with positive antibody tests?

Rallying cries around COVID-19 have shifted from “flatten the curve” to “reopen America.” After weeks of restrictions on movement, commerce, and social connections across most areas of the country, the tantalizing possibility of relaxing current measures in time for summer baseball and beach parties eroded the resolve of many communities in lockdown. At least 30 states have already moved to reopen some businesses or loosen stay-at-home orders against the warnings of health experts. In the context of a growing array of roadmaps intended to guide policy makers toward the next phase of the response, there is another rallying cry that needs to be heard most loudly right now: “Fund public health.”

Digital epidemiology—the use of data generated outside the public health system for disease surveillance—has been in use for more than a quarter century [see supplementary materials (SM)]. But several countries have taken digital epidemiology to the next level in responding to COVID-19. Focusing on core public health functions of case detection, contact tracing, and isolation and quarantine, we explore ethical concerns raised by digital technologies and new data sources in public health surveillance during epidemics. For example, some have voiced concern that trust and participation in such approaches may be unevenly distributed across society; others have raised privacy concerns. Yet counterbalancing such concerns is the argument that “sometimes it is unethical not to use available data”; some trade-offs may be not only ethically justifiable but ethically obligatory. The question is not whether to use new data sources—such as cellphones, wearables, video surveillance, social media, internet searches and news, and crowd-sourced symptom self-reports—but how.

During the severe acute respiratory syndrome (SARS) outbreak in 2003, Taiwan reported 346 confirmed cases and 73 deaths. Of all known infections, 94% were transmitted inside hospitals. Nine major hospitals were fully or partially shut down, and many doctors and nurses quit for fear of becoming infected. The Taipei Municipal Ho-Ping Hospital was most severely affected. Its index patient, a 42-year-old undocumented hospital laundry worker who interacted with staff and patients for 6 days before being hospitalized, became a superspreader, infecting at least 20 other patients and 10 staff members. The entire 450-bed hospital was ordered to shut down, and all 930 staff and 240 patients were quarantined within the hospital. The central government appointed the previous Minister of Health as head of the Anti-SARS Taskforce. Ultimately the hospital was evacuated; the outbreak resulted in 26 deaths. Events surrounding the hospital’s evacuation offer important lessons for hospitals struggling to cope with the COVID-19 pandemic, which has been caused by spread of a similar coronavirus.

BACKGROUND

Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership.

METHODS

We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns).

RESULTS

A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition.

CONCLUSIONS

Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.)