As covid-19 spreads around world, China has touted its efforts to bring the novel coronavirus outbreak swiftly under control under President Xi Jinping’s leadership. Bruce Aylward of WHO’s China mission commended China’s “bold approach”, saying that the “the key learning from China is speed — it’s all about the speed”.
But the real story is more complex. Although China’s national authorities acted decisively after Jan. 23, there were key deficiencies at the outset. Here’s what you need to know:
1. Politics overruled the truth
Wuhan, the capital of Hubei province, was getting ready in early January for the Jan. 6-17 “two sessions”, where local and provincial leaders would gather to discuss the state of affairs at the local/provincial levels. These sessions take place annually throughout China, and authorities mobilize stability maintenance systems to get rid of troublemakers and forestall protests. Local authorities are also motivated by the desire to hide undesirable developments from Beijing.
When experts from Beijing arrived to investigate the atypical pneumonia outbreak, Wuhan officials tried to avoid two things: upsetting Beijing; or causing a public panic in advance of these two important meetings. So they took a multipronged approach to control information about the outbreak.
Between Dec. 31 and Jan. 20, China’s National Health Commission (NHC) dispatched three teams of experts to Wuhan. The first two teams struggled to gather evidence that the novel coronavirus was contagious from human to human. They were stymied by local interests intent on keeping the epidemic under wraps so that their political bosses could hold their annual meetings in a calm atmosphere.
2. Local officials silenced whistleblowers
The punishment meted out to Li Wenliang, an ophthalmologist, and others who shared information about local transmission had a chilling effect on doctors. Ai Fen, a physician who shared the “SARS-like” lab results with Li, was head of emergency care at Wuhan Central Hospital. Based on the cases she saw in late December, she concluded the disease was probably human-to-human contagious and alerted the hospital authority. But the hospital’s Supervision Department admonished her for “spreading rumors and causing trouble … and causing social panic”.
A Hubei Health Commission official also called a company that did the viral sequencing and directed the company to stop the sequencing from Wuhan — although these tests would have been a useful indicator of the spread of the novel coronavirus that causes the disease covid-19.
3. Local officials kept the expert groups in the dark
On Jan. 3, the Wuhan municipal health commission (WHC) announced that the national and Hubei provincial health commissions had sent expert teams to Wuhan to offer their guidance. Interviews with the experts reveal that senior WHC officials and hospital administrators chaperoned the expert groups closely. Reportedly, the experts were not free to talk to doctors in the emergency care and infectious diseases wards, which would probably have revealed valuable insights on the new virus, including the number of infected health-care workers.
Li Wenliang was already hospitalized on Jan. 10 — which would have offered powerful evidence of human-to-human transmission. We now know about a cluster of infections at Union Hospital, where a doctor and 13 nurses involved in one operation became infected by the patient and began to show symptoms around Jan. 12.
Members of the second expert group “always suspected” human-to-human transmission. But when they visited hospitals and inquired about medical staff infections, hospital leadership and the doctors they met invariably told them there were none.
Wang Guangfa, an expert team member who became infected, wrote on Feb. 4: “Regarding disease infectivity and population susceptibility, we did not have any data to confirm it at the time”. Another team member was blunt about the suppression of specifics about human-to-human transmission: “They didn’t tell us the truth, and from what we now know of the real situation then, they were lying [to us]”.
4. The WHC restricted the diagnostic criteria
On the surface, the WHC deferred to national authorities and the Beijing/Hubei experts’ joint “Treatment Plan for Viral Pneumonia of Unknown Etiology” (VPUE). This plan notes that, epidemiologically, most cases in treatment had exposure to the Huanan Seafood Market or similar exposures. Using the phrasing “most cases” left the door open to include patients with no exposure to the Huanan Market, where the coronavirus is thought to have first jumped from animals to people working there.
The WHC, however, set its own, more restrictive criteria and communicated these criteria directly to hospital officials but emphasized the Huanan Market exposure. This meant hospitals relied on this marker as a necessary condition for diagnosis.
Hospitals applying the stricter diagnostic criteria could not report any VPUE cases even when their own staff apparently became infected. One doctor concluded that the criteria for diagnosing VPUE cases “were so strict, not a single patient met [them]”.
A doctor at a major Wuhan hospital who overrode the stringent criteria and submitted the probable cases received “stern criticism” from hospital leadership. Barricaded behind the restrictive criteria and with doctors too afraid to speak up, the WHC effectively made the coronavirus outbreak disappear while Hubei provincial leaders held their “two sessions” on Jan. 11-17.
Beginning on Jan. 11, WHC announced “zero” new cases. These zeros, repeated daily, had a powerful soothing effect. Xu Jianguo, head of the first NHC expert group to Wuhan, predicted in mid-January: “This epidemic is limited and will end if there are no new cases next week”.
Pronouncements like this lulled the public as well as most medical staff into a false sense of security. Most doctors in Wuhan failed to take precautions even though they saw a growing number of patients with symptoms of the new pneumonia-like virus, resulting in high numbers of medical staff infections.
What are the real lessons from China?
China’s governance system has prized growth while maintaining stability — but central-local tensions and bureaucratic shortfalls complicate this picture. The threat of instability — like this outbreak — tends to see local authorities deploy a combination of carrots and sticks to control information and restore order.
But when central-local interests diverge, as was the case with the covid-19 outbreak, the tensions produced feigned compliance, distortion and subterfuge. Since Jan. 20, China’s leadership has launched an unprecedented national campaign to contain the novel coronavirus. This enormously costly drive seems to be paying off, and reported new cases in China have dwindled. But China, along with the rest of the world, is paying a huge price for these initial delays.
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.