防疫「一體」？臺灣21世紀蚊媒傳染病的系統風險治理與關鍵變遷

Abstract

本研究以21世紀全球登革熱大流行為背景，借鏡臺灣瘧疾防治的歷史經驗，觀察時過境遷之下，我們的防疫體制如何因應蚊媒傳染病的動態發展與轉變。藉由歷史制度主義所關注的「制度變遷」理論導引出制度創建的「關鍵契機」，以及對後續發展的重要作用。為建立歷史脈絡的動態分析，透過質性訪談法逐步探討當代蚊媒傳染病防治的風險與實務問題，同時關注臺灣為何、如何重塑風險治理下的新制度變革，並且交叉檢視訪談資料與既有文獻之間的系統紋理。最後，透過全球衛生倡議的人、蚊、環境健康風險共同體的「防疫一『體』」概念，檢視臺灣「防疫體制」與蚊媒傳染病治理的互動關係與運作困境；並進一步論述蚊媒傳染病如何促使人類與環境互為「風險一體」，以及防疫體制如何承接風險，關鍵地重塑組織與制度變革的問題。 研究發現，登革熱的本質是層層交織的系統風險。由於複雜的致病機制導致目前仍存在未知與未竟的「醫療端」風險，並且限縮了「公衛端」防治的基礎邏輯。此外，登革熱並非唯一的防治對象，相同病媒蚊種可傳播至少三種蚊媒傳染病。同時，在現今全球跨境移動與氣候暖化的雙重驅力下，出現既有流行風險版圖的鬆動跡象。2015年、2023年兩次臺灣嚴峻的登革熱疫災，成為重塑風險治理下的關鍵契機，並且內嵌於防疫體制的漸進變革之中。然而，「治蚊體制」的現實運作仍受到中央與地方政府垂直協調、水平治理權責分配的影響，尚須回歸「防疫一體」落實困境的討論。

This research stems from the background of dengue outbreaks around the world in the 21st century, draws on Taiwan's historical experiences in malaria prevention and control, and observes how our bureaucracies of diseases control and prevention has adapted to the dynamic development and transformation of mosquito-borne diseases over time. Based on the theory of“Institutional Change”that Historical Institutionalism focuses on, the“critical juncture”for institution innovation and its critical implications in subsequent development are guided. In order to establish a dynamic process analysis of historical context, this research used qualitative interview method to gradually explore the risks and practical issues of contemporary mosquito-borne disease prevention and control; at the same time, focus on why and how Taiwan is reshaping new institutional changes under risk governance, and observe the systematic texture between the interview data and existing literature. Finally, according to the concept of“One Health”of the Global Health Initiative’s human, mosquitoes, and environmental health risk community, we observe the interactive relation and practical difficulties between Taiwan’s“bureaucracies”of diseases control and prevention and the governance of mosquito-borne diseases ; and further discuss how mosquito-borne diseases make humans and the environment become the one risk community, and how the“bureaucracies”takes on risks, critically reshapes the issues of organizational and institutional change. The research found that the nature of dengue fever is intertwined systemic risks. Due to the complex pathogenic mechanism, there are still unknown and undone risks about“medical”interventions, and the basic logic of “public health”prevention and control has been restricted. In addition, dengue fever is not the only target of prevention and control, the same vector can transmit at least three mosquito-borne diseases. Meanwhile, under the dual driving forces of today’s global transboundary movement and climate warming, there are signs of loosening of the existing epidemic risk landscape. The two severe dengue fever epidemics in Taiwan in 2015 and 2023 have become the critical junctures to reshape risk governance and are embedded in the incremental changes of the bureaucracies. However, the practical operation of the“mosquito control bureaucracies”is still affected by the vertical and horizontal division of authority and responsibility between the central and local governments, and it is necessary to return to the discussion of the dilemma over implementing“One Health”.