After Sars, Chinese health officials built an infectious disease reporting system to evade political meddling. But when the coronavirus emerged, so did fears of upsetting Beijing.
The alarm system was ready. Scarred by the Sars epidemic that erupted in 2002, China had created an infectious disease reporting system that officials said was world-class: Fast, thorough and, just as important, immune from meddling.
Hospitals could input patients' details into a computer and instantly notify government health authorities in Beijing, where officers are trained to spot and smother contagious outbreaks before they spread.
It didn't work.
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After doctors in Wuhan began treating clusters of patients stricken with a mysterious pneumonia in December, the reporting was supposed to have been automatic. Instead, hospitals deferred to local health officials who, over a political aversion to sharing bad news, withheld information about cases from the national reporting system — keeping Beijing in the dark and delaying the response.
The central health authorities first learned about the outbreak not from the reporting system but after unknown whistleblowers leaked two internal documents online.
Even after Beijing got involved, local officials set narrow criteria for confirming cases, leaving out information that could have provided clues that the virus was spreading among humans.
Hospitals were ordered to count only patients with a known connection to the source of the outbreak, the seafood market. Doctors also had to have their cases confirmed by bureaucrats before they were reported to higher-ups.
As the United States, Europe and the rest of the world struggle to contain the coronavirus pandemic, China has cast itself as a model, bringing down a raging outbreak to the point where the country has begun to lift the kinds of onerous restrictions on life that are now imposed around the world.
This triumphant narrative obscures the early failures in reporting cases, squandered time that could have been used to slow infections in China before they exploded into a pandemic.
"According to the rules, this of course should have been reported," Yang Gonghuan, a retired health care official involved in establishing the direct reporting system, said in an interview. "Of course they should have seized on it, found it, gone to understand it."
Aggressive action just a week earlier in mid-January could have cut the number of infections by two-thirds, according to a recent study whose authors include an expert from Wuhan's municipal Center for Disease Control and Prevention. Another study found that if China had moved to control the outbreak three weeks earlier, it might have prevented 95 per cent of the country's cases.
"I regret that back then I didn't keep screaming out at the top of my voice," Ai Fen, one of the doctors at Wuhan Central Hospital who spotted cases in December, said in an interview with a Chinese magazine. "I've often thought to myself what would have happened if I could wind back time."
China's leader, Xi Jinping, has sought to move quickly past the early failings and shift attention to the country's drive to end the outbreak. The Chinese government has been widely castigated for its initial mistakes, which have become a top talking point of President Donald Trump.
The central leadership has focused blame on local bureaucrats, including for censuring doctors who warned others about the infections. It promptly dismissed two health officials and, later, the party secretaries for Hubei province and its capital, Wuhan.
Now, interviews with doctors, health experts and officials, leaked government documents, and investigations by Chinese media reveal the depth of the government's failings: How a system built to protect medical expertise and infection reports from political tampering succumbed to tampering.
Others tried to fill the void of information when the early warning system failed. The medical community found other, informal ways to alert others, disclosing government directives and hospital reports on the internet. During a rare burst of relative transparency early in the epidemic, Chinese journalists did much to expose the problems, but censors closed that window.
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The government has vowed to fix flaws exposed in the disease surveillance system, but similar promises were made after Sars. Fresh efforts to repair the system now could also falter under a political hierarchy that leaves experts — doctors, even public health officials — unwilling to take on local leaders. In China, politics often ends up overriding the very safeguards created to prevent interference in the flow of information.
The failures in the first weeks "greatly reduced the vigilance and self-protection of the public and even medical workers, making it harder to contain the epidemic," said a study of the epidemic by 12 medical experts from Shanghai Jiao Tong University. "Only precautions in ordinary times can prevent great disasters from arising."
Preparing for the worst
Last year, health officials exuded confidence that China would never again suffer a crisis like Sars.
In July, the Chinese Center for Disease Control and Prevention held what it called the nation's biggest infectious outbreak training exercise since the Sars epidemic in 2002 and 2003, showcasing the strides that the government had made since the virus killed hundreds and traumatized the nation.
More than 8,200 officials took part in the online drill, focused on a traveler arriving from abroad with a fever who sets off temperature monitors, triggering a hunt for other passengers. The officials raced to test how quickly and effectively they could track, identify and contain the virus, including by notifying Beijing.
"Who knows what the next one will be?" said Feng Zijian, a senior disease control official who helped design the exercise, according to the center.
"The enemy is constantly evolving," Feng said, "and our capacity to respond must also constantly improve."
At the heart of China's defenses was the Contagious Disease National Direct Reporting System. Started in 2004, it was designed to prevent a repeat of the Sars epidemic, when slow, patchy reporting, compounded by local leaders' reluctance to share bad news, delayed the government's fight.
Using this system, health officers in Beijing could pore over screens showing reports from hospitals or local disease control centers, ready to spot warning signs within a few hours of a doctor diagnosing a troublesome infection, such as cholera or tuberculosis, as well as hard-to-diagnose cases of viral pneumonia.
"Viruses like Sars could emerge anytime, but there'll never be another Sars incident," Gao Fu, director of China's disease control center, said in a speech last year. "That's thanks to how well our national contagious disease surveillance system works."
The boasts were not empty.
The system had helped when China and other countries suffered outbreaks of bird flu. In 2013, authorities filed cases of a potentially deadly H7N9 bird flu virus, with orders to submit them within two hours of confirmation.
Last November, the country's Center for Disease Control alerted the public to an outbreak of pneumonic plague in the sparsely populated Inner Mongolia, after only two cases emerged.
Since the outbreak in Wuhan, some doctors have said they were unsure how to report early cases, which did not fit into the standard list of infections. But little-understood infections could still be logged as "pneumonia of unknown etiology" — or unknown cause — when patients did not respond to the usual treatment.
Year after year, Chinese health authorities warned hospitals to look out for such outliers.
"For many infectious diseases when you don't know the cause, it can often present itself as pneumonia of unknown etiology," said Yang, the retired official. "This was a way of capturing an outbreak while it was embryonic."
Health authorities held regular meetings to train disease control officials in spotting and investigating unexplained and hard-to-treat pneumonia cases; the last was in Shanghai in October.
They inspected hospitals and local disease control centers to try to ensure that they were reporting all listed diseases, and the National Health Commission demanded 100% compliance. Although implementation was patchy, doctors reported a handful of unusual pneumonia infections, galvanizing investigators to track down the cause.
In early December, Hubei's local Center for Disease Control called together officials from across the province to instill the system's importance.
Huang Xibao, a deputy director of the center, told them to make sure that in 2020 Hubei was "number one nationwide in the overall quality of its contagious disease information."
'Far worse'
Ai, the head of the intensive care unit at Wuhan Central Hospital, was among the first doctors to note a disturbing pattern among patients staggering into the city's hospitals with dry coughs, high fevers and crippling lethargy. Computerized tomography or "CT" scans often revealed extensive damage to their lungs.
"It was a baffling high fever," Ai said of a patient who turned up on December 16, according to an interview in a Chinese magazine called People. "The medicines used throughout didn't work, and his temperature didn't move."
By the end of the month, local disease control centers in Wuhan were receiving worried calls from doctors, telling of the strange, tenacious pneumonia cases that often seemed to emanate from the Huanan seafood market. Seven in one hospital, three in another, three in yet another.
"These patients may be infectious. Caring for them in a general hospital is a safety risk," warned Huang Chaolin, a senior doctor at Jinyintan Hospital, the city's main facility for infectious diseases. He saw seven patients from another hospital on December 27, according to a report in the Health News, the official newspaper of the medical system.
In theory, doctors could have reported such cases directly, but Chinese hospitals also answer to Communist Party bureaucracies. Over time, hospitals often came to defer to local health authorities about reporting troublesome infections, apparently to avoid surprising and embarrassing local leaders.
That deference may not have mattered much most of the time. Now it gave officials in Wuhan an opening to control and distort information about the virus.
Local disease control offices in the city had counted 25 such cases by December 30, said an official internal report that was leaked online last month by unknown whistleblowers. The brief document was one of the first attempts by Wuhan to understand the extent of cases, and listed patients had fallen ill starting December 12.
"The local health administration clearly made a choice not to use the reporting system," said Dali Yang, a professor of political science at the University of Chicago who studies policymaking in China. "It is clear they were trying to resolve the problem within the province."
Leaders in Wuhan seem to have assumed that the outbreak would peter out like bursts of avian flu infection — short-lived and localized — Shao Yiming, a virologist at the Center for Disease Control, said in an interview with Caixin, a Chinese magazine.
"This fixed mindset caused errors in judgment, so we lost the opportunity to early on adopt encircling tactics and tell the public how to self-protect," Shao said.
Word of the outbreak started to reach disease control officials in Beijing after rumors and the leaked documents began to spread online. The national center for disease control has pointedly avoided saying in announcements that it had been notified by Wuhan, instead noting that it had "learned of" the outbreak. Local officials have hedged over when and how they told Beijing.
The leaked documents were two internal Wuhan government directives, which emerged online on December 30, possibly released by worried medical workers. The directives, marked "urgent," ordered hospitals to send the city health commission information about cases of the mysterious pneumonia, improve treatment of patients and avoid infection in hospitals. At the same time, doctors alerted colleagues to the outbreak in private group chats on social media, which prompted official reprimands.
Gao Fu, the director of the Center for Disease Control, spotted the information circulating online and raised alarms, according to an account by Hua Sheng, a prominent Chinese economist who has defended the center. Gao declined to answer questions. The center ordered teams of experts to rush to Wuhan, and the first group arrived by the next morning.
"News that pneumonia of unknown cause had emerged in Wuhan shook the nerves of every emergency response worker in the Chinese Center for Disease Control," said a report issued by the center.
Officials from the National Health Commission have said that they ordered Wuhan to issue its first official announcement on the outbreak on December 31. That day the government also informed the World Health Organization's office in Beijing.
Some of the first cases were finally entered into the system on January 3, though by then it was too late to serve as the early warning system it was intended to be.
Narrow criteria
When the central government became involved, local officials outwardly welcomed the expert investigators sent by Beijing. Officials described the infections as nothing too serious.
"They said that the illness was quite light, not much different from seasonal influenza, and there'd been no illnesses among hundreds of people with close contact," Zeng Guang, a Chinese epidemiologist who visited Wuhan on Jan. 9, said of his talks there, according to the China Youth Daily. "They sounded very relaxed."
Behind the scenes, officials in Wuhan mounted an effort to limit the number of infections counted as part of the outbreak, creating barriers against doctors filing cases.
A leaked report from Wuhan Central Hospital describes how in the first half of January local officials told doctors that cases had to be confirmed by bureaucratic overseers, above all, city and province health authorities.
An official from a district disease control center in Wuhan told the hospital doctor handling infection reports on January 3 that "this was a special contagious disease and we should report only after superiors had notified us," the leaked report said.
Starting on January 3, Wuhan's Health Commission set narrow criteria for confirming that a case was officially part of the outbreak, according to a copy of the diagnostic guide that was leaked to the Chinese media, possibly by a medical professional. The rules said patients could be counted if they had been to the market or had close contact with another patient who had. That excluded a growing number of likely cases with no clear link to the market.
For most of the first half of January, local officials maintained that there had been no new confirmed infections, even as doctors in Wuhan and visiting experts suspected that a dangerous contagion was spreading from person to person.
"I lived through Sars, and to me the early period of this epidemic felt shockingly like Sars," Li Liming, a Peking University professor of public health who was among the experts sent to Wuhan, told a Chinese newspaper. "In both, there was no rapid system response at the start."
Zhong Nanshan, a disease expert who helped identify Sars, was also skeptical of the official optimism in Wuhan after visiting the city and hearing from his former students there.
He and other experts finished their assessment of Wuhan on January 19, convinced the virus had gained a menacing foothold, and conveyed their alarm to senior officials in meetings in Beijing.
"All the members of the expert team reported that the situation was grim," Yuen Kwok-yung, a professor of infectious diseases at the University of Hong Kong who was among the expert group, told Caixin magazine. "Preventive measures had to fall in place immediately."
After weeks of reporting no new infections, the Wuhan government disclosed four new cases on January 18, followed by 17 the next day and 136 the next.
Four days later, Wuhan was shut down to contain the spread.
At the time, the coronavirus had killed 26 people and sickened more than 800. By Sunday, there were more than 670,000 cases worldwide; more than 31,000 people have died.
Written by: Steven Lee Myers
© 2020 THE NEW YORK TIMES