For whom the warning system tolls after China’s virus crisis

The year 2020 has finally passed and Wuhan, the city where the Covid-19 pandemic first broke out, seems to have returned to normal. A closer look, however, shows that the city has not recovered from its wounds.

The period between Christmas and New Year’s Day is usually a busy time for shopping, yet many malls look cheerless. The Wuhan Jinyintan Hospital, which specializes in infectious disease, remains partly closed. The hospital still focuses on treating new Covid-19 cases,  although, according to official data, there are very few new cases and these are imported from abroad.

Back then the condition was still called “pneumonia of unknown etiology” and had not yet been confirmed as a new disease caused by a novel coronavirus.  Neither doctors nor the general public knew much about the illness.

Since January 2020, however, there have been many turning points that might have changed the course of the pandemic, said Dr. Zhang Qi. It is a shame, he added, that so many “crucial moments” were mishandled.

A country’s response to a major public health event can reflect all aspects of its administrative system, pandemic prevention mechanism, public health preparedness level, and social structure. In the case of China, the country’s initial response to the Covid-19 pandemic revealed deep-seated problems within its public health system.

Had Chinese officials properly used the country’s disease control mechanism, heeded the warnings of its experts, or released infection data early, the virus might not have spread out of control, resulting in serious consequences for the citizens of Wuhan and the rest of the world.

Infectious disease surveillance system

In theory, China was well-positioned to detect the novel coronavirus and subsequently sound an early warning. More than a decade ago – after the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS – the Chinese Centers for Disease Control and Prevention (CDC) established the China Disease Prevention and Control Information System, also known as the Network Direct Reporting System. 

The core of this system is the National Notifiable Disease Reporting System (NNDRS), which facilitates real-time, online reporting of cases of infectious disease. This system has two important features.

First, it covers the entire country and shares data with all computers in township hospitals. Second, it uses a system of “direct reporting.” As long as a hospital reports a case to the network, disease control departments at all levels, including the CDC in Beijing, receive the report immediately. CDC employees monitor the system and write daily analysis reports.

When more than five cases of unidentified pneumonia are identified in one area, the verification mechanism is automatically triggered and the CDC sends personnel to conduct patient visits and epidemiological investigations. This warning mechanism even includes a special plan for surveilling the so-called pneumonia of unknown etiology (PUE).

These protocols have been in place since 2004.  By the end of 2011, the system covered 100% of disease control institutions, 98% of county-level as well as above medical and health institutions, and 88% of township health centers across the country. According to a paper written by researchers from the CDC, this system played a major role in the early detection and reporting of human infection of avian flu.

But the system did not fulfill its early warning role during the Covid-19 pandemic. So far, the CDC has not clearly explained how the system was used this time. In Fighting COVID-19: China in Action, an official publication released by the State Council Information Office in June, the PUE monitoring system was not mentioned once. 

Hua Sheng, a well-known Chinese economist based in Beijing, stated that the CDC director saw information about infection cases on the Internet – and not from the direct reporting system – on December 30, 2019. Later a CDC leader claimed that the hierarchy present in the chain of reporting increased the time it took for news to reach the national level. However, this statement contradicts the early warning system’s “direct reporting” feature.

Regardless of how the disease surveillance mechanism was used, the CDC did not disclose information about the pandemic to the public. In fact, it lacked the authority to do so. China’s CDC can collect and analyze data, but is not a decision-making body.

Instead, it is merely one of a hundred organizations – along with other centers, hospitals, and research institutions—that are under the direct supervision of the National Health Commission (NHC). By law, it is the NHC that is responsible for sharing infectious disease information.

Hua Sheng, speaking to China Newsweek in February, compared the Covid-19 situation to the 2003 SARS outbreak and said that China “fell in the same river twice.” Though the country’s science and technology capacities are much higher now than in 2003, “the carefully crafted warning system became the Maginot Line in this war on epidemics [;]the line was lost before the war even started!”

Experts versus officials

On December 31, 2019, the NHC sent a group of medical experts – primarily officials from the disease control system and doctors – to Wuhan. The second group of experts was sent to Wuhan from January 8 to January 16.

Such an action shows that the central government had paid close attention to the pandemic very early on. However, public remarks from experts and media reports afterward make clear that these experts – dispatched to investigate whether “human-to-human transmission” of the virus had occurred – encountered great resistance locally. 

According to a report from Caijing magazine published in February 2020, local hospitals and health commission officials in Hubei and Wuhan refused to fully cooperate. “This was the main problem”, one member of an expert group told Caijing anonymously. The experts found that their power was restricted. The local government took the lead, and the expert group could only assist, unable to provide meaningful information to the public.

Ultimately, human-to-human transmission was not confirmed to the public until January 20, after Chinese medical expert Zhong Nanshan visited Wuhan. Zhong Nanshan is an epidemiologist and physician who gained a reputation for his work during the SARS crisis and has been leading the NHC’s Covid-19 expert panel.

Before traveling to Wuhan, Zhong Nanshan had asked local doctors to determine whether any medical staff infections had occurred in the city’s main hospitals. He did not trust the words of local government officials, who had incentives to minimize the perceived risk of the virus.

In China, the relationship between the central and local governments has always been fraught. On the surface, the central government issues orders while the local governments implement them. In practice, local governments have a great deal of leeway in bargaining for their own interests during the implementation process.

If problems arise, local government leaders would rather solve them behind closed doors than reveal them to their superiors, because exposing problems diminishes their political status. During one meeting in Wuhan, according to the same report from the Caijing Magazine, experts from the NHC asked the local officials to report truthfully. In response, the leaders of the local health commission asked: “Do you suspect that I am concealing the report?”

Key Meeting

During the initial investigations, a crucial meeting took place at the Wuhan Municipal Health Commission on January 10. The meeting, organized by the provincial health commission, included the second batch of experts, as well as provincial and municipal health officials, members of local CDC departments, and doctors and virologists from Wuhan.

Dr Zhang Qi participated in this meeting. That night, he explained, there was controversy regarding which cases to announce. Wuhan provided case data:  41 cases confirmed by laboratory test results and over 100 suspected cases that had not yet undergone testing.

The expert group demanded that both suspected and confirmed cases be reported and also asked that suspected patients be treated in isolation. Yet the next day, the local government announced only the 41 confirmed cases.

For Dr Zhang Qi, this meeting was a missed opportunity, one that he will never forget. It showed that experts had lost against administrative power. Public health workers make decisions based on science, but science is only one consideration for government officials, and definitely not their primary concern, in general, as well as at that time. 

The meeting happened to be held right before Hubei entered the “two sessions” period, preparing for China’s two top political meetings held annually in Beijing. Maintaining stability is paramount during the Two Sessions, and strictly controlling negative news is of utmost importance. Until the end of the Two Sessions in Hubei on January 16,2020,  the official case number of 41 did not increase.

Desperate doctors

Looking back, it was the local doctors in Wuhan who first understood the situation and tried to tell the world, even as the public was left in the dark. On December 27, 2019,  Dr Zhang Jixian from Hubei Integrated Traditional Chinese and Western Medicine Hospital reported the mysterious symptoms exhibited by several patients to the district health authorities. She is now considered to be the person who discovered the novel coronavirus. 

Doctors were the first to propose using fever as a diagnostic criteria for Covid-19 and to be wary of human-to-human transmission. Some hospitals activated higher levels of protection, opened isolation wards, and stored protective clothing. Others canceled group dinners and reminded colleagues and family members to take precautions. In short, the doctors strove to accept patients, renovate wards, and improve treatment conditions.

Unfortunately, much of this information and expertise was suppressed. In China, hospitals are strictly managed. If hospital revelations cause panic, there will be repercussions from the Chinese Communist Party which motivates administrators to keep the situation under wraps.

“To some extent, the Chinese government treats the public’s response as a ‘bacteria’, and then desperately [applies] the dose of antibiotics,” said Liu Shaohua, an anthropologist and the author of Leprosy Doctors in China’s Imperial Experimentation: Metaphors of Disease and Its Control (2018).

The way forward may have been clear according to science, but political concerns can override expertise. This was the case during the January 10 meeting and it was also the attitude toward many doctors who dared to speak up, trying to break through the obstruction to convey real information to the public.

It was the dynamic present at Wuhan Central Hospital, one of the first large public hospitals to receive infected patients, where leaders displayed insensitivity and a lack of professional knowledge that was also reflected by their superiors.      

On December  30,  2019, Dr Ai Fen, head of the emergency department at the Wuhan Central Hospital, took a photo of lab results from a patient with PUE. She circled the word “SARS” coronavirus in red and passed the results on to her colleagues.

The next day, Dr Li Wenliang, an ophthalmologist at the same hospital, shared the photo with his former medical school classmates in a private WeChat group, also alerting them to this “SARS-like” coronavirus.

Quickly punished

As the source of the leak, Dr Ai Fen was quickly punished. She was interviewed by the hospital’s disciplinary committee and “suffered an unprecedented and very severe reprimand.” According to a report from  Chinese People Magazine, Cai Li, the secretary of the Party Committee of Wuhan Central Hospital, called Dr Ai Fen “the criminal who affects the stability and unity of Wuhan” and “the culprit who undermines the development of Wuhan.” 

Dr Li Wenliang faced consequences that were even more severe. On January 3, 2020, he and seven other doctors were taken by the police, questioned, and forced to sign a letter promising that they would not release relevant remarks in the future. 

The police admonished Li Wenliang, stating that “your behavior has seriously disrupted social order and exceeded the scope permitted by the law […] If you continue to engage in illegal activities, you will be punished by law.” Dr Li Wenliang died of Covid-19 in February 2020 and is called the “whistleblower” of this pandemic.

These stories from Wuhan Central Hospital are numerous. In one case, Jiang Xueqing, the director of the thyroid and breast surgery department, wore a mask to attend a meeting. After being criticized by the hospital leaders, he stopped and eventually died after contracting Covid-19.

At one point, facing a shortage of supplies, the medical staff asked for help, but were discouraged by the hospital and prohibited from collecting  private donations. During the pandemic, hundreds of medical staff were infected with the disease and many died from the infection, making it the most severely damaged hospital in Wuhan.

Afterward, some doctors in the city reflected on what might have been. Had any hospital dared to take the lead and quarantined fever patients – as would be common sense given the symptom profile of those affected – there may have been no pandemic. But under such circumstances and in regards to this context, which hospital leader would dare to take the initiative?

Public health reflections

The pandemic has spurred the Chinese government to investigate the weaknesses of its public health system. One of the problems is related to this system’s very structure.

Huang Qifan, a former senior official of the Chinese Communist Party and the former mayor of Chongqing, has pointed out that the CDC in the United States reports directly to the president’s health and safety committee and is independent of the conventional medical and health management system.

In short, the US CDC is a separate agency with its own powers while China’s CDC does not enjoy the same amount of independence. Experts such as Zhong Nanshan, the well-known Chinese doctor, have argued that the status of the disease control agency is too low and it should instead have “a certain degree of administrative power.”

Others have suggested that China’s public health and pandemic prevention system be elevated to the national level, with an independent governance system. Meanwhile, Gao Fu, the director of the CDC at the national level, said that the key to reform of the disease control system is “not whether you have administrative power, but whether you have technical work free from administrative interference.”

Changes related to public health and disease prevention have been implemented in Beijing, as well as in Hubei province. In April 2020, Tsinghua University announced the establishment of the School of Public Health, with Margaret Chan, the former Director-General of the World Health Organization, as the dean.

In July, Wuhan established six hospitals, including four large third-level grade-A hospitals and two national medical centers, with a total investment of more than 10 billion yuan (1.546 billion). Also in July, Hubei approved the establishment of a chief public health officer in provincial, municipal, and county health authorities on a trial basis. Additionally, the work of disease control will now be included in the performance assessment of medical institutions.

Another reform worthy of attention is the introduction of a system to encourage and protect whistleblowers. In September of this year, the “Beijing Municipality Regulation on the Urgent Handling of Public Health Emergencies” was passed and put into effect. It improves public health emergency monitoring sentinels located at ports, airports, stations, schools, wholesale markets, and other locations. Anyone has the right to report public health emergencies and non-malicious false reports will not be held accountable.

Now, as other countries are doing their best to control the pandemic, the situation in China is relatively safe and stable. As a result, the recognition has begun. In June, China released the white paper detailing China’s fight against the Covid-19 pandemic and preaching its success. Subsequently, a grand ceremony commending anti-pandemic activities swept the country.

Government officials, experts, and medical staff took to the red carpet and stood on the podium. In October, under the guidance of the party’s Central Propaganda Department, Wuhan held an exhibition glorifying the fight against the Covid-19 pandemic.

Wuhan fight

Chinese officials have repeatedly emphasized the country’s “institutional advantage”; the ability to marshal the best. The introduction to this exhibition also claimed that the success of Wuhan’s fight against the coronavirus “fully demonstrates the remarkable advantages of the socialist system.”

“In the face of this daunting challenge and severe test the people in Hubei and Wuhan demonstrated broad vision (???), selfless devotion (???), perseverance and tenacity,” the exhibition stated. As I, in a prior article, described, Wuhan residents showed a strong spirit of volunteerism and dedication in the fight of Covid-19.

However, in the official language, terms like “broad vision” and “selfless devotion” also mean that individual voices have to be silenced. Using the same vocabulary, Cai Li, the then secretary of the Party Committee of Wuhan Central Hospital, reprimanded doctors such as Li Wenliang and Ai Fen for “disrupting the big picture of Wuhan’s development.” “China still [has] a ‘post-empire’ mentality,” said Liu Shaohua the anthropologist, regarding China’s performance in the face of Covid-19.

While this top-down approach effectively controls undesirable behavior, it is questionable whether it can be used to react to unpredictable challenges with the same effectiveness, as the failure of the infectious disease warning systems demonstrated. 

(Zhang Qi is a pseudonym in the text)

Liu Cong is a social science scholar living in Wuhan.

This article first appeared in echowall on December 16. To read the original version click on this link.

Echowall is a collaborative research platform based at the University of Heidelberg’s Institute of Chinese Studies in Germany.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy of China Factor.