In the six days after top Chinese officials secretly determined that they were likely facing a pandemic from a new coronavirus, Wuhan — the epicenter of the disease — hosted a mass banquet for tens of thousands of people and millions began traveling through the city for the Lunar New Year holiday.
Chinese President Xi Jinping (習近平) warned the public on the seventh day, Jan. 20, but by that time, more than 3,000 people had become infected during almost a week of public silence, internal documents and expert estimates based on retrospective infection data showed.
Six days — that delay from Jan. 14 to Jan. 20 was neither the first mistake made by Chinese officials at all levels in confronting the outbreak, nor the longest lag, as governments around the world have dragged their feet for weeks and even months in addressing the virus.
Illustration: Constance Chou
However, the delay by the first country to face COVID-19 came at a critical time — the beginning of the outbreak. China’s attempt to walk a line between alerting the public and avoiding panic set the stage for a pandemic that has infected 2.25 million people and taken more than 150,000 lives.
“This is tremendous,” University of California, Los Angeles (UCLA) epidemiologist Zhang Zuo-feng (張作風) said. “If they had taken action six days earlier, there would have been much fewer patients and medical facilities would have been sufficient. We might have avoided the collapse of Wuhan’s medical system.”
Other experts have said that the Chinese government might have acted quickly in private, but waited on warning the public to stave off hysteria.
Internal bulletins showed that the six-day delay by Beijing came on top of almost two weeks during which the Chinese Center for Disease Control and Prevention (CDC) did not register any cases from local officials, but during that time, from Jan. 5 to Jan. 17, hundreds of patients were appearing in hospitals — not just in Wuhan, but across the country.
It is uncertain whether it was local officials who failed to report cases or national officials who failed to record them. It is also not clear exactly what officials knew at the time in Wuhan, which only lifted its lockdown less than two weeks ago.
Experts have said that China’s rigid controls on information, bureaucratic hurdles and a reluctance to send bad news up the chain of command muffled early warnings. The punishment of eight doctors for “rumor-mongering,” broadcast on national television on Jan. 2, sent a chill through the city’s hospitals.
“Doctors in Wuhan were afraid,” University of Chicago Chinese politics professor Dali Yang (楊大力) said. “It was truly intimidation of an entire profession.”
Without these internal reports, it took the first case outside China, in Thailand on Jan. 13, to galvanize leaders in Beijing into recognizing the possible pandemic before them. It was only then that they launched a nationwide plan to find cases — distributing CDC-sanctioned testing kits, easing the criteria for confirming cases and ordering health officials to screen patients, all without telling the public.
The Chinese government has repeatedly denied suppressing information in the early days, saying that it immediately reported the outbreak to the WHO.
“Allegations of a cover-up or lack of transparency in China are groundless,” Chinese Ministry of Foreign Affairs spokesman Zhao Lijian (趙立堅) told a news conference on Thursday.
Documents show that Chinese National Health Commission Minister Ma Xiaowei (馬曉偉) laid out a grim assessment of the situation on Jan. 14 in a confidential teleconference with provincial health officials.
A memo states that the teleconference was held to convey instructions on the coronavirus from Xi, Chinese Premier Li Keqiang (李克強) and Chinese Vice Premier Sun Chunlan (孫春蘭), but does not specify what those instructions were.
“The epidemic situation is still severe and complex, the most severe challenge since SARS in 2003, and is likely to develop into a major public health event,” the memo quotes Ma as saying.
The National Health Commission is the country’s top medical agency.
It organized the teleconference because of the case reported in Thailand and the possibility of the virus spreading during Lunar New Year travel, the commission said in a faxed statement, adding that China published information on the outbreak in an “open, transparent, responsible and timely manner,” in accordance with “important instructions” repeatedly issued by Xi.
The documents come from an anonymous source in the medical field who did not want to be named for fear of retribution. The Associated Press (AP) confirmed the contents with two other public health sources familiar with the teleconference. Some of the memo’s contents also appeared in a public notice about the teleconference, stripped of key details and published in February.
Under a section titled “sober understanding of the situation,” the memo said that “clustered cases suggest that human-to-human transmission is possible.” It singled out the case in Thailand, saying that the situation had “changed significantly” because of the possible spread of the virus abroad.
“With the coming of the Spring Festival, many people will be traveling, and the risk of transmission and spread is high,” the memo added. “All localities must prepare for and respond to a pandemic.”
In the memo, Ma demanded that officials unite around Xi, and made clear that political considerations and social stability were key priorities during the long lead-up to the year’s two biggest political meetings, held last month. While the documents do not spell out why Chinese leaders waited six days to make their concerns public, the meetings might be one reason.
“The imperative for social stability, for not rocking the boat before these important [Chinese Communist] Party congresses, is pretty strong,” Yale University political science professor Daniel Mattingly said. “My guess is, they wanted to let it play out a little more and see what happened.”
In response to the teleconference, the CDC in Beijing initiated the highest-level emergency response internally, level 1, on Jan. 15.
It assigned top CDC leaders to 14 working groups tasked with getting funds, training health workers, collecting data, doing field investigations and supervising laboratories, an internal CDC notice showed. The memo directed Hubei Province, where Wuhan is located, to begin temperature checks at airports, bus stations and train stations, and to cut down on large public gatherings.
The National Health Commission also distributed a 63-page set of instructions to provincial health officials, which ordered health officials nationwide to identify suspected cases, hospitals to open fever clinics, and doctors and nurses to don protective gear. The instructions were marked “internal,” “not to be spread on the Internet” and “not to be publicly disclosed.”
However, in public, officials continued to downplay the threat, pointing to the 41 cases made public at the time.
“We have reached the latest understanding that the risk of sustained human-to-human transmission is low,” Chinese CDC Public Health Emergency Center head Li Qun (李群) told Chinese state television on Jan. 15 — the same day that Li was appointed as leader of a group preparing emergency plans for the level 1 response, a CDC notice showed.
On Jan. 20, Xi issued his first public comments on the virus, saying that the outbreak “must be taken seriously” and every possible measure pursued, and leading Chinese epidemiologist Zhong Nanshan (鍾南山) announced for the first time that the virus was transmissible from person to person on national television.
If the public had been warned a week earlier to take action — such as practicing social distancing, wearing masks and restricting travel — cases could have been cut by up to two-thirds, one paper later found.
An earlier warning could have saved lives, Zhang said.
However, other health experts have said that the government took decisive action in private, given the information available to them.
“They might not have said the right thing, but they were doing the right thing,” said Ray Yip (葉雷), the retired founding head of the US Centers for Disease Control and Prevention’s office in China. “On the 20th, they sounded the alarm for the whole country, which is not an unreasonable delay.”
If health officials raise the alarm prematurely, it can damage their credibility — “like crying wolf” — and cripple their ability to mobilize the public, University of Hong Kong epidemiologist Benjamin Cowley said.
The delay might support accusations by US President Donald Trump that the Chinese government’s secrecy held back the world’s response to the virus, but even the public announcement on Jan. 20 left the US nearly two months to prepare for the pandemic.
During those months, Trump ignored the warnings of his own staff and dismissed the disease as nothing to worry about, while the government failed to bolster medical supplies and deployed flawed testing kits.
Leaders across the world turned a blind eye to the outbreak, with British Prime Minister Boris Johnson calling for a strategy of “herd immunity” — before falling ill himself. Brazilian President Jair Bolsonaro sneered at what he called “a little cold.”
The early story of the pandemic in China shows missed opportunities at every step, documents and interviews showed. Under Xi, China’s most authoritarian leader in decades, increasing political repression has made officials more hesitant to report cases without a clear green light from the top.
“It really increased the stakes for officials, which made them reluctant to step out of line,” Mattingly said. “It made it harder for people at the local level to report bad information.”
Doctors and nurses in Wuhan told Chinese media that there were plenty of signs as early as the end of December last year that the coronavirus could be transmitted between people. Patients who had never been to the suspected source of the virus, the Huanan Seafood City market, were infected and medical workers started falling ill.
However, government officials obstructed medical staff who tried to report such cases, setting tight criteria for confirming cases, where patients not only had to test positive, but samples had to be sent to Beijing and sequenced. Officials required staff to report to supervisors before sending information higher, according to Chinese media reports, and they punished doctors for warning about the disease.
As a result, no new cases were reported for almost two weeks from Jan. 5, even as officials gathered in Wuhan for Hubei Province’s two biggest political meetings of the year, internal CDC bulletins confirm.
During this period, teams of experts dispatched to Wuhan by Beijing said that they failed to find clear signs of danger and human-to-human transmission.
“China has many years of disease control. There’s absolutely no chance that this will spread widely because of Spring Festival travel,” the head of the first expert team, Xu Jianguo (徐建國), told the Hong Kong newspaper Ta Kung Pao on Jan. 6, adding that there was “no evidence of human-to-human transmission” and that the threat from the virus was low.
The second expert team, dispatched on Jan. 8, similarly failed to unearth any clear signs of human-to-human transmission, but during their stay, more than half a dozen doctors and nurses fell ill with the virus, a retrospective CDC study published in the New England Journal of Medicine would later show.
The teams looked for patients with severe pneumonia, missing those with milder symptoms. They also narrowed the search to those who had visited the seafood market — which in hindsight was a mistake, said Cowling, who flew to Beijing to review the cases in late January.
In the weeks after the severity of the outbreak became clear, some experts accused Wuhan officials of intentionally hiding cases.
“I always suspected it was human-to-human transmissible,” the leader of the second expert team, Wang Guangfa (王廣發), wrote in a March 15 post on Weibo. He fell ill with the virus soon after returning to Beijing on Jan. 16.
Then-Wuhan mayor Zhou Xianwang (周先旺) blamed national regulations for the secrecy.
“As a local government official, I could disclose information only after being authorized,” Zhou told state media in late January. “A lot of people didn’t understand this.”
As a result, top Chinese officials appear to have been left in the dark.
“The CDC acted sluggishly, assuming all was fine,” said a state health expert, who declined to be named out of fear of retribution. “If we started to do something a week or two earlier, things could have been so much different.”
It was not just Wuhan. In Shenzhen in southern China, hundreds of kilometers away, a team led by microbiologist Yuen Kwok-yung (袁國勇) used their own testing kits to confirm that six members of a family of seven had the virus on Jan. 12.
In an interview with financial magazine Caixin, Yuen said that he informed CDC branches “of all levels,” including Beijing, but CDC bulletins showed that internal numbers did not reflect Yuen’s report.
When the Thai case was reported, health authorities finally drew up an internal plan to systematically identify, isolate, test and treat all cases of the coronavirus nationwide.
Wuhan’s case count began to climb immediately — four on Jan. 17, then 17 the next day and 136 the day after.
Across the country, dozens of cases began to surface, in some cases among patients who were infected earlier, but had not yet been tested. For example, in Zhejiang, a man hospitalized on Jan. 4 was only isolated on Jan. 17 and confirmed positive on Jan. 21. In Shenzhen, the patients that Yuen had discovered on Jan. 12 were finally recorded as confirmed cases on Jan. 19.
The Peking Union Medical College Hospital held an emergency meeting on Jan. 18, instructing staff to adopt stringent isolation — still before Xi’s public warning.
A health expert said that on Jan. 19, she toured a hospital built after the SARS outbreak, where medical workers had furiously prepared an entire building with hundreds of beds for pneumonia patients.
“Everybody in the country in the infectious disease field knew something was going on,” she said, declining to be named to avoid disrupting sensitive government consultations. “They were anticipating it.”
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