Improving Surge Capacity for Biothreats:

Experience from Taiwan

Fuh-Yuan Shih, MD, Kristi L. Koenig, MD

Abstract
This article discusses Taiwan’s experience in managing surge needs based on recent events, including the
1999 earthquake, severe acute respiratory syndrome in 2003, airliner crashes in 1998 and 2001, and yearly
typhoons and floods. Management techniques are compared and contrasted with U.S. approaches. The
authors discuss Taiwan’s practices of sending doctors to the scene of an event and immediately recalling
off-duty hospital personnel, managing volunteers, designating specialty hospitals, and use of incident man-
agement systems. The key differences in bioevents, including the mathematical myths regarding individual
versus population care, division of stockpiles, the Maginot line, and multi-jurisdictional responses, are
highlighted. Several recent initiatives aimed at mitigating biothreats have begun in Taiwan, but their effi-
cacy has not yet been tested. These include the integration of the emergency medical services and health-
facility medical systems with other response systems; the use of the hospital emergency incident command
system; crisis risk-communications approaches; and the use of practical, hands-on training programs.
Other countries may gain valuable insights for mitigating and managing biothreats by studying Taiwan’s
experiences in augmenting surge capacity.
ACADEMIC EMERGENCY MEDICINE 2006; 13:1114–1117 ª 2006 by the Society for Academic Emergency
Medicine
Keywords: surge, surge capacity, biothreat, bioevent, Taiwan

T
aiwan has experienced a multitude of disasters in
recent times, including yearly typhoons and floods,
a huge earthquake in 1999,1 airplane crashes in
1998 and 2001,2 and severe acute respiratory syndrome
(SARS) in 2003.3 These mass casualty or complex inci-
dents created demands that challenged the medical and
public health infrastructure. Emergency medical pre-
paredness programs evolved in response to medical
surge needs for these disasters.
Several approaches have been adopted to expand
medical-care delivery systems aimed at managing increased
volumes of patients with unusual medical needs. Medical
response plans in Taiwan and many other Asian countries
(because of their similar cultural backgrounds and social
norms) have several characteristics that differ from plans
in the United States. These include the following:
From the Emergency Department of National Taiwan University
Hospital (F-YS), Taipei, Taiwan; and the University of California
at Irvine, School of Medicine (KLK), Orange, CA.
Received June 19, 2006; revision received June 27, 2006; ac-
cepted June 30, 2006.
Presented at the Academic Emergency Medicine Consensus
Conference, ‘‘Establishing the Science of Surge,’’ San Francisco,
CA, May 17, 2006.
Address for correspondence and reprints: Kristi L. Koenig, MD.
E-mail: kkoenig@uci.edu.
1. The plans require immediate dispatch of hospital-
based physicians to incident sites without first
assessing whether the scene has been secured
or whether physician care on the scene would
improve patient outcomes.4,5 The emergency medi-
cal services (EMS) system of Taiwan was established
in 1995, and the responding firefighters were trained
to be emergency medical technicians (EMTs).6 Nearly
half of the EMTs are EMT-I trained (60 hours training),
and the remainder are EMT-II trained (264 hours
training). Despite this, people believe that physicians
at the scene can provide better medical care than
can firefighter–EMTs. There is an expectation from
both the public and the politicians that physicians
will report to the scene of an incident after a media
call for help. Although some physicians may possess
the experience and training to improve scene triage
and provide definitive medical care when indicated
at an event scene, many hospital physicians lack the
requisite skills in scene safety and austere trauma
care. In addition, when personnel from the emergency
department (ED) of a smaller hospital are deployed to
the scene, the hospital then may lack adequate capac-
ity to receive patients. Requests for physician assis-
tance at the scene also can be confusing when the
frontline of an event is obscure, as for example in
the case of a biothreat.
2. The plans tend to call for all off-duty personnel to
report immediately to the hospital.7 Although this

ISSN 1069-6563 ª 2006 by the Society for Academic Emergency Medicine

1114 PII ISSN 1069-6563583 doi: 10.1197/j.aem.2006.06.044
ACAD EMERG MED  November 2006, Vol. 13, No. 11  www.aemj.org
procedure can generate adequate human resources for
the first few hours, it can prematurely deplete person-
nel resources in a prolonged emergency, because there
is no backfill to relieve the first wave of staff. The time
curve of casualty numbers found and treated after the
Chi-Chi earthquake in 1999 (Figure 1) is available be-
cause of a requirement that health care workers report
casualty encounters to the central government. The
curve illustrates the effects of a procedure that calls
for all available personnel to report to work immedi-
ately after a disaster. The data show that patient treat-
ment dips precipitously 24 hours after the event. It is
probable that this occurred because most of the rescue
workers and medical personnel were exhausted after
working continuously for a prolonged period, so oper-
ations were temporarily shut down.
3. The plans rely on a substantial number of volunteers
responding to the surge demand. There is a belief
that there will be many volunteers during disasters, and
it is socially inappropriate to refuse their participation.2
Functions filled by volunteers include provision of
psychological support, transportation, and supplies
needed for activities of daily living. For disasters that
are familiar to civilians such as earthquakes, typhoons,
or multivehicle traffic collisions, a simple call from the
media can activate thousands of volunteers. The situa-
tion changes when the hazards are exotic and sub-
stantial perceived risk exists for the responders.8 For
example, in the SARS outbreak in Taiwan in 2003,
when a community hospital was isolated because of
the internal spread of disease, only dozens of people
volunteered despite a vigorous countrywide govern-
ment-run campaign.8 Some surveys predict that the
same phenomenon will happen in radiation and hazard-
ous material (hazmat) incidents in Taiwan.9
4. The plans usually designate specialty receiving
centers.3 Because it is easier and more cost-effective
to provide equipment and personnel training to a lim-
ited number of hospitals, specialty hospitals are desig-
nated in some cities for natural disasters, multiple-
casualty incidents, hazmat incidents, radiation acci-
dents, and biohazard events. Medical societies em-
brace this policy because these designated hospitals
are the only ones required to maintain training and
equipment. This approach is problematic, however,
because it does not account for self-presentation of
victims after a disaster or emergency to a nearby facil-
ity, rather than a designated one. This is especially
true for an emerging infectious-disease scenario.10
5. The plans tend to lack the necessary functional-
area expertise for a robust incident command
structure and overemphasize clinical skills, espe-
cially for chemical- biological- radiological-nuclear-
explosive (CBRNE) events. Medical and health
infrastructures are poorly organized for an emergency
situation. Most of the command structures are staf-
fed by experts from the medical profession, whereas
the logistics, administration and finance, and plan-
ning personnel are not activated.11 For a familiar
and short-lasting hazard, such a command structure
has been shown to be effective; however, for an
unfamiliar and long-lasting event, logistics support
within such a command structure usually is insufficient.
1115
Figure 1. Casualty flow after 1999 Taiwan earthquake.
A biothreat is different from other disasters in several
ways: it is usually insidious in onset with a covert origin;
it is relatively slow at first but progressively escalating;
and victims require unique laboratory and epidemiologic
investigations and may not be easily recognized. Coun-
termeasures that successfully augment medical capacity
and capability in other hazards may not be effective
against this threat.
There are several mathematical myths inherent in
many response plans:
1. The myth of simple multiplication of individual
care. Mathematically, one times one thousand equals
one thousand times one, but separate care for one
thousand individual victims is not equivalent to popu-
lation care for one thousand people at a time. We tend
to manage multiple-casualty incidents with the same
model used for a single trauma patient by simply pro-
viding an extraordinary number of responders. In fact,
the mainstay of many emergency plans is to summon
as many responders as possible. This may be effective
in some limited-scale events, but in more complicated
situations such as SARS, the logistics for individual
care escalate exponentially when casualty numbers in-
crease, and the system collapses if we fail to adapt and
provide a population-care model.12,13
2. The myth of simple division of a stockpile. If there
are one thousand apples for one hundred people,
mathematically, each person will have ten apples.
However, in reality, the efficiency of dispatch deter-
mines who gets the apples and how many. Resource
management is more than simple division. Too often
we focus on how many resources we have in a phar-
maceutical stockpile, coupled with the number of vic-
tims who require medications, but we forget that the
supply management is the determinant factor.12,13
3. The myth of the Maginot Line. In the wake of World
War I, the French constructed the Maginot Line, a line
of concrete fortifications, tank obstacles, machine-gun
posts, and other defenses along its borders with Ger-
many and Italy. They believed that this fortification
would provide time for their army to mobilize and
would compensate for their relatively small numbers,
but this plan failed. Likewise, despite lack of a compre-
hensive strategy, we believed that a fortification line of
specialty receiving centers, experts, and specialized
laboratories would provide time for responders to
mobilize in the event of an attack and would also com-
pensate for numerical weakness. For example, during
the SARS epidemic in Taiwan, a failure in a single
1116 Shih and Koenig  IMPROVING SURGE CAPACITY FOR BIOTHREATS: EXPERIENCE FROM TAIWAN
hospital resulted in community-wide spread of the dis-
ease to the entire metropolitan area. The infrastruc-
ture of the health system should be fortified and
adequate training and equipment provided, especially
for general care, casualty transportation systems, sur-
veillance, sanitation, public education, crisis risk com-
munication, and information technology.14
4. The myth of multi-jurisdictions. In a cage, there are
birds, rabbits, and monsters. In total, there are 12
heads and 41 legs. Can we determine the numbers of
birds, rabbits, and monsters? We cannot, because
we do not know how many heads and legs one
monster has. When a complex event occurs, multiple
disciplines may be called into action, including public
safety, public health, human resources, and emer-
gency management. Because these communities do
not routinely work together, they are unfamiliar with
each other’s procedures. In emergency response, the
monsters, which are the untrained, uncontrolled, and
unreliable responders, will cause the system to be-
come paralyzed. Other hazards include the self-pro-
claimed experts and the omnipotent media, which
can be more destructive than well-meaning people
who simply are ignorant.15
Facing the potential challenges from avian influenza,
some actions have been adopted based on the experience
of SARS. In comparison to other Asian countries, the
medical resources in Taiwan are luxurious. In Taipei
City, population 2.6 million, there are 13,000 hospital
beds, and 30% of them are typically unoccupied. Despite
these abundant resources, coordination between sys-
tems needs improvement. To augment the surge capacity
and capability of the medical system, several projects
have recently been implemented:
1. The out-of-hospital and health care facility medical
systems are being integrated with other emergency
response systems, including hazmat and nuclear
accident and bioterrorism medical care systems.
Medical resources can be shared by different hospitals
to optimize care of patients received from the field.
2. Hospitals are required to adopt an emergency inci-
dent command system that balances command, op-
erations, and logistics in emergencies. No hospital
is immune to disasters, so basic medical preparedness
for all hospitals is mandatory per new hospital-accred-
itation criteria.
3. Crisis and risk communication training is provided
for appropriate personnel. CBRNE is exotic for this
community, so public concern and confusion can
paralyze the health care system. A robust and honest
risk-communications program that directs people to
medically appropriate care can ease the risk to the
public and preserve the health care system for those
who truly need medical attention.
4. Practical, hands-on training is provided for medi-
cal and health responders. The objective of the train-
ing is to ensure that responders will be able to
competently and efficiently perform their jobs accord-
ing to the plan and is not to convert health care pro-
viders into instant experts. The training programs
have shifted their focus from biological incidents to
an all-hazards approach that focuses on the opera-
tional skills that health care providers are asked to
perform after an incident.
Through these efforts, Taiwan plans to build a robust
and efficient framework for health authorities that max-
imizes their ability to provide adequate medical eval-
uation and care for all kinds of mass-casualty and
complex incidents that exceed the normal medical capac-
ity and capability. This will be a critical component of the
community safety network.
CONCLUSIONS
Taiwan is a country with vast experience in managing di-
sasters and that has much knowledge to share regarding
how to enhance surge capacity for a bioevent. Although
new initiatives remain untested, other systems can gain
valuable insights by studying the pros and cons of vari-
ous approaches to increasing surge capacity, the mathe-
matical myths for a biothreat, and the actions initiated by
Taiwan after the SARS outbreak and in the face of the
looming threat of avian influenza.
References
1. Liang NJ, Shih YT, Shih FY, et al. Disaster epidemiol-
ogy and medical response in the Chi-Chi earthquake
in Taiwan. Ann Emerg Med. 2001; 38:549–55.
2. Lee WH, Chiu TF, Ng CJ, Chen JC. Emergency
medical preparedness and response to a Singapore
airliner crash. Acad Emerg Med. 2002; 9:194–8.
3. Twu SJ, Chen TJ, Chen CJ, et al. Control measures for
severe acute respiratory syndrome (SARS) in Taiwan.
Emerg Infect Dis. 2003; 9:718–20.
4. Hsu EB, Ma M, Lin FY, VanRooyen MJ, Burkle FM Jr.
Emergency medical assistance team response follow-
ing Taiwan Chi-Chi earthquake. Prehospital Disaster
Med. 2002; 17:17–22.
5. Chen KT, Chen WJ, Malilay J, Twu SJ. The public
health response to the Chi-Chi earthquake in Taiwan,
1999. Public Health Rep. 2003; 118:493–9.
6. Bullard JM, Liaw SJ, Chen JC. Emergency medicine
development in Taiwan. Ann Emerg Med. 1996; 28:
542–8.
7. Chen WK, Cheng YC, Ng KC, Hung JJ, Chuang CM.
Were there enough physicians in an emergency
department in the affected area after a major earth-
quake? An analysis of the Taiwan Chi-Chi earthquake
in 1999. Ann Emerg Med. 2001; 38:556–61.
8. Editorial board, Taipei Times. Time for Sense and
Conscience. Available at: http://www.taipeitimes.com/
News/editorials/archives/2003/04/30/204097. Accessed
Jun 27, 2006.
9. Shih FY. Radiation emergency medical care pre-
paredness in Taiwan. Proceedings of International
Radiation Emergency Medical Care Workshop. Na-
tional Association of Radiation Protection. Taipei,
Taiwan, July 29–30, 2005.
10. Wu D. Hospital is closed over SARS fears. Taipei
Times. 2003; Apr 30:1. Available at: http://www.
taipeitimes.com/News/front/archives/2003/04/30/204039.
Accessed Jun 27, 2006.
ACAD EMERG MED  November 2006, Vol. 13, No. 11  www.aemj.org
11. Chiang WC, Shih FY, Chang KJ, Chen WJ. Prob-
lems of immediate medical care at community
hospitals of Taipei during Typhoon Nari, 2001.
6th Asia-Pacific Conference on Disaster Medicine.
Fukuoka, Japan, 2002. Prehospital Disaster Med.
2002; 17:S21.
12. Ko S. Experts warns of health-care hole. Taipei Times.
2003; May 7:3. Available at: http://www.taipeitimes.
com/News/taiwan/archives/2003/05/07/204989. Ac-
cessed Jun 27, 2006.
1117
13. Centers for Disease Control and Prevention. Severe
acute respiratory syndrome—Taiwan. MMWR Morb
Mortal Wkly Rep. 2003; 52:461–6.
14. Shih FY. SARS—a global threat, Taiwan experience.
Annual Conference of National Disaster Medical Sys-
tems, Dallas, TX, Apr 17–21, 2004.
15. Editorial board, Taipei Times. We Need to Close the
Loopholes. Available at: http://www.taipeitimes.com/
News/editorials/archives/2003/05/11/205544. Accessed
Jun 27, 2006.