Chinese authorities have placed an estimated 760 million people into lockdown as part of an epic campaign to contain the spread of covid-19, the novel coronavirus. As of Sunday, there were over 77,000 confirmed cases and more than 2,500 deaths in China, mostly in Hubei province. Wuhan, the provincial capital and the epicenter of the outbreak, has been hard hit.
Why did China’s CDC system, once touted as among the world’s best disease control programs, fail to help contain the virus early on? And what has the crisis exposed about China’s system of governance? Here’s what you need to know.
China built a system to prevent another SARS crisis
In the aftermath of the 2003 SARS crisis, China invested heavily to improve its system for infectious disease control and prevention. These measures included new laboratories and a nationwide Infectious Diseases Reporting System, as well as new laws on infectious diseases control and public health emergencies. The reporting system is extensive, covering all of China’s more than 2,800 county-level jurisdictions.
In a country known for its bureaucratic hierarchy, this information system is designed for attention escalation — and rapid response. Hospitals with infectious diseases cases input the cases into the info system, and this information needs to reach the China CDC within hours. A dedicated team at the China CDC headquarters monitors the information flows 24/7 and reports to the CDC leadership at least once a day.
This sentinel system for infectious diseases helped China tackle various outbreaks — including H1N1, avian flu and malaria. Successive China CDC directors have taken great pride in this system. In a March 2019 interview, Gao Fu, the China CDC director general, said he was “very confident that the SARS incident will not recur. This is due to our country’s well-built infectious disease surveillance network; we can block the virus when it appears”.
The system worked, according to local authorities
The official story in Hubei and Wuhan is that, after identifying atypical pneumonia cases, the Wuhan and Hubei CDCs forwarded the information on a timely basis to the national CDC at the end of December. To drive home this message, the Hubei authorities on Feb. 4 announced a merit award to Dr. Zhang Jixian for getting her hospital to report several cases to municipal and provincial authorities on Dec. 29, 2019.
The Wuhan Health Commission (WHC) began to release information on its website on the atypical pneumonia cases on Dec. 31, 2019.
But local authorities didn’t tell the full story
The China CDC official line, however, suggests a different timeline. According to Feng Zijian, deputy director general of the China CDC, the direct reporting system was “not activated that expeditiously”. In fact, the award to Zhang for reporting on Dec. 29 reminds us that the pre-Dec. 29 cases were not reported, let alone filed into the disease reporting system in real time.
Two separate sources reveal that Gao Fu himself was the real sentinel of the coronavirus outbreak. In the evening of Dec. 30, Gao Fu noticed from scanning group-chats that the WHC had just issued two internal notices on atypical pneumonia cases. Alarmed that such information had not been submitted to the national reporting system, he called the Wuhan CDC head and learned that the number of cases was well above the threshold for reporting. Troubled by what he heard — and didn’t hear — Gao immediately alerted the National Health Commission (NHC) leadership. The following day, Dec. 31, the NHC dispatched a national team of experts to Wuhan to investigate.
Local authorities also silenced whistleblowers
As the national team was on its way to Wuhan, the WHC issued its first public statement about the atypical pneumonia outbreak, reassuringthe public that the health administrations and hospitals were managing the situation well. Of the 27 cases, “seven were critical, but the rest were stable and controllable, including two that …are expected to be discharged”. In fact, the latest retrospective study by China CDC reveals there were already 104 cases, including 15 deaths, in December.
What ensued in Wuhan has received enormous coverage. As Wuhan and Hubei political leaders met in Wuhan for annual meetings, WHC kept the number of the infected artificially low, and repeatedly downplayed the risks of contagion. Wuhan officials also pushed ahead with large public gatherings ahead of the lunar New Year, which helped spread the virus.
In contrast, on Jan. 2, health authorities in Singapore and other countries began to screen passengers from Wuhan.
The case of Dr. Li Wenliang has captured global attention. Early on Dec. 31, Dr. Li was reprimanded by WHC and the Wuhan Central Hospital he worked at for spreading false rumors about SARS-like cases on Dec. 30. Police later forced him to sign a document promising not to spread “false rumors” again. Other doctors were also admonished for “irresponsible behavior that caused social panic and disrupted Wuhan’s development and stability”.
Systemic fissures contributed to further delays
Local officials, including Wuhan’s mayor, blamed their inadequate public disclosure on the need to secure approval from above. But the truth is more complicated. We now know that on Dec. 30, a joint Hubei-Wuhan CDC investigation team concluded that there were no clusters of cases but there were nonetheless a family of several members that became infected.
Had China CDC experts seen this report — or engaged with the infectious disease doctors at the major Wuhan hospitals — they would likely have recognized earlier that the virus was spreading from human to human. Three crucial weeks would elapse before a new national experts team, including Dr. Zhong Nanshan and Gao Fu, finally concluded that the coronavirus was highly contagious.
The infectious diseases sentinel system only works if the hospitals and local health administrations actively engage with it and contribute to the information. In Wuhan, the system failed, monumentally. The failure has laid bare the inherent tensions of a reporting system that is also beholden to the political imperatives of provincial and municipal Communist Party bosses.
For now, President Xi Jinping has replaced the top leaders of Hubei and Wuhan. China remains in the midst of an unprecedented and enormously costly effort to contain covid-19. While the Chinese leadership can lay some of the blame for the crisis on local missteps, a more effective public health emergency response system will depend on encouraging information flows and realigning institutional interests.
Dali L. Yang is the William C. Reavis Professor of Political Science at the University of Chicago. His research has emphasized governance and regulation in China.