The Regret of Wuhan: How China Missed the Critical Window for Controlling the Coronavirus Outbreak

By Li Xiangyu (李想俣), Li Mingzi (李明子), Peng Danni (彭丹妮), and Du Wei (杜玮), in the February 10 issue of China News Weekly

Out of mountains of reports about the coronavirus epidemic, we at China Change have taken a keen interest in two areas: the origins of the virus, and the decision making process. The cover story of China News Weekly (中国新闻周刊), published on February 5, put together a detailed timeline and asked the right questions. Within a day, the article was deleted from the magazine’s own website as well as major Chinese news portals. Luckily, the report is preserved in various news aggregate sites outside China in both simplified and traditional Chinese (武汉之憾：黄金防控期是如何错过的？). The timeline it presented focuses on the discovery of early coronavirus cases, local government’s responses in the seven weeks from December 1 to January 20, what the local and national Center for Disease Control and Prevention did in that period, and without directly raising the question, how the most critical decisions, especially the decision to downplay the outbreak in the first weeks, were made at the State Council and ultimately by the Communist Party leaders in Zhongnanhai. Unfortunately, we still don’t know much about the first case of the 2019-nConV. This is a translation of the censored article. We added notes at various points of the text to provide more details and context, and links are embedded for your easy reference. – The Editors

December 31, 2019 saw an announcement that interrupted the Chinese people’s joyous spirit as they prepared to usher in the new year. Circulating on social media sites was a red-letterhead document bearing the official seal of the Wuhan Municipal Health Commission (武汉市卫健委) and sounding an emergency notice: “Cases of a pneumonia of unknown cause have intermittently surfaced at Wuhan’s Huanan Seafood Market.”

The notice sparked immediate concern: could it be a new SARS outbreak?

The very day prior, Dr. Li Wenliang (李文亮) at Wuhan Central Hospital heard from his colleagues that seven SARS patients who had been at the seafood market were being quarantined in the hospital’s Emergency Department. At around 5 p.m. that day he shared a message with his fellow college alumni in a WeChat group, explaining that “it’s not entirely accurate to call it SARS, it seems to be a coronavirus. But its specific composition awaits confirmation.” He encouraged those in the group to be mindful of their safety, while also telling them to keep the information confidential. However, a screenshot of his WeChat post showing the line “seven SARS cases confirmed at Huanan Seafood Market” was leaked from the group and spread quickly throughout the internet.

At around 1:30 a.m. on December 31, Li Wenliang got a phone call summoning him to the Wuhan Municipal Health Commission. “The Health Commission was holding an overnight conference, probably a discussion on how to handle the outbreak. All leaders at our hospital and infirmary were in attendance,” Li said. After the meeting, the hospital leaders interrogated him on the source of his message, and let him go home around 4 a.m. When day came, Li went to the hospital’s supervisory department another two or three times, where he was repeatedly questioned on his knowledge of the infections and whether or not he was aware of the “mistake of spreading rumors.” He was ordered to write a self-criticism to reflect on the topic of “not spreading misinformation.”^[1]

That afternoon, the Wuhan Health Commission issued a notice: “recently, some medical organizations have diagnosed multiple cases of pneumonia in connection with the Huanan Seafood Market: the total number of cases has reached 27, of which seven of the patients are in critical condition.” The notice went on to say that “obvious signs of human-to-human transmission have yet to be discovered, and no medical staff are known to have contracted the illness.”

The first team of experts from the National Health Commission (NHC) arrived in Wuhan the same day.

The Wuhan government’s notice quickly dampened discussion of the topic. Many felt relieved, confident that they had made it soundly into the third decade of the 21st century. Who knew that it was just the beginning of a nationwide crisis that would eclipse the scale of the SARS epidemic and, within a month, be deemed a “global health emergency” by the World Health Organization?

‘Cold Handling’

After Wuhan first issued its notice about the “pneumonia of unknown cause” on December 31, a reporter from China News Weekly (中国新闻周刊) went to the Huanan Seafood Market. The reporter found that business at the market was still lively, and very few people were wearing masks. According to vendors, the market was disinfected multiple times following the outbreak. Huanan has been in operation for many years, hosting about 600 vendor spots in its eastern and western halves. It is situated in the middle of Wuhan, just a kilometer away from Hankou railway station.

A Wuhan resident described the “squalid” scenes at Huanan: “They ostensibly sell seafood, but actually they’ve got a reputation for hawking cats and dogs, live snakes and turtles, various types of pheasant, marmot, sika deer, live monkeys, and other [exotic meats].”

Under the scrutiny of reporters who arrived at the scene in the rush to cover the story, Huanan Seafood Market formally closed on January 1, 2020, in order to bring its practices in line with regulation. Following this, Zuo-Feng Zhang (张作风), tenured Professor of Epidemiology and associate dean at UCLA’s Fielding School of Public Health, pointed out that as early as December 8, multiple people at the Huanan market had contracted a novel coronavirus according to later announcements made by the Wuhan health authorities. Professor Zhang said that had steps been taken within that week to close down the market and quarantine the patients, suspected cases, and anyone else they had come into contact with, the outbreak would never have become so severe. Instead, during the intervening 22 day until January 1 when the Huanan market was finally closed, many more Wuhan residents were exposed to the virus, and the best window of opportunity for controlling the contagion was lost.

Also on New Year Day, the Wuhan Public Security Bureau’s official Weibo account, @PeacefulWuhan (@平安武汉), made a post saying that “a number of citizens have, in the absence of verification, published and circulated untruthful information, bringing about an adverse impact on society. After conducting an investigation to verify the situation, the public security organs have summoned eight persons who acted unlawfully, and have now been handled according to the law.”

The Weibo post was deleted some 20 days later.

In the morning of January 3, Li Wenliang received another call, this time from the police station. He was summoned there and made to sign a “letter of reprimandation” (训诫书) regarding the “untruthful statements” he had made online. Following this, the department head at his hospital gave spoken instructions not to spread information related [to the virus] on the internet.

Lin Yu (林羽, alias), a doctor at the Union Hospital (协和医院)^[2] affiliated with Huazhong University of Science and Technology’s Tongji Medical School (同济医学院) described his recollections in an interview with China News Weekly. He said that at the beginning of the outbreak, the Wuhan municipal government’s policy for dealing with the problem was “cold handling” (冷处理). The hospital where Lin worked issued a notice saying that barring explicit permission from the work unit, no one was allowed to discuss the sickness using their personal communication channels or give interviews with the media. In addition to the clinical system, information was also strictly controlled at the hospital infection-control department and at the CDC. “You weren’t allowed to say anything all.” The only thing the doctor could do was repeatedly exhort those seeking treatment: “wear masks, you must buy and wear masks.” They also made loaded jokes, like “avoid Huanan Seafood Market, the products there aren’t fresh.”^[3]

From January 6 to January 10, the Wuhan Health Commission made no announcements about the status of the outbreak. These four days coincided with the convening of the “Two Sessions” (两会) in Wuhan.

Xu Jianguo (徐建国), of the Chinese Academy of Engineering, and leader of the expert team tasked with evaluating test results on the Wuhan pneumonia, said on January 9 that that the preliminary conclusion they have arrived at was that the pathogen that had infected several people in Wuhan took the form of a coronavirus. According to information leaked by insiders, the initial expert team, in addition to Xu, also included Li Xingwang (李兴旺) who chairs the research and treatment department of infectious and sexually transmitted disease department at Beijing’s Ditan Hospital, and Cao Bin (曹彬)— whose titles include director of the respiratory and acute disease medical institute at the China-Japan Friendship Hospital in Beijing.

On January 11, the Wuhan Health Commission announced that the number of confirmed cases had risen to 41, including one patient who had died; the commission repeated that “no health worker has been found to have contracted the disease, and no clear human-to-human transmission has been established.” The same day, Wang Guangfa (王广发), a member of the national team of medical experts and director of the respiratory and acute medical department at Peking University’s First Hospital, gave an interview with reporters, saying that the situation in Wuhan was “preventable and controllable.” (可防可控)

But 11 days later, it became known that Wang Guangfa himself had contracted the pneumonic virus. For a time, he was the focal point on social media. On February 1, after making a full recovery, Wang said that from the case materials they had seen at the time — the initial report on 41 cases that had been published in The Lancet — absolutely no medical workers were infected.

A person with inside knowledge told China News Weekly that the second team of experts was in Wuhan between January 8 and January 16 to direct epidemic prevention work. This team included Wang Guangfa; Second Department head doctor Jiang Rongmeng (蒋荣猛) of the Ditan Hospital; Gao Zhancheng (高占成), director of the respiratory disease and internal medicine department at Peking University People’s Hospital; and other clinical experts. Also in the group were China CDC deputy director Feng Zijian (冯子健) and former deputy director Yang Weizhong (杨维中), among other disease control experts.

In connection with this, in the early morning of January 15, the Wuhan Municipal Health Commission issued a “Q & A on the Novel Coronavirus Pneumonia Outbreak.” In this document, the official description regarding the infectiousness of the new coronary pneumonia was changed for the first time: “no clear evidence of human-to-human transmission has been found, and the possibility of limited human-to-human transmission cannot be ruled out, but the risk of sustained human-to-human transmission is low.” The first appearance of multiple people in the same family contracting the disease was also confirmed that day. In one sick couple, the wife denied that she had been at the Huanan market.

No new cases of the disease were reported in Wuhan between January 12 and January 17. During this period, the Hubei provincial Chinese People’s Political Consultative Conference and the Hubei People’s Congress [the two organizations that host the “Two Sessions”] held their meetings .

But in the few days that went by without any newly reported cases from Wuhan, cases of the coronavirus began to appear in foreign countries. On January 13, the Thai authorities reported that a pneumonia patient had been diagnosed with the Wuhan coronavirus. On January 16, Japan confirmed its first case. The patient was a Chinese citizen, but had not been to the Huanan market. It’s possible that the patient had been in close contact with someone suffering from the new pneumonia. Thailand announced a second case on January 17: a 74-year-old woman of Chinese nationality. In response to these reports, the U.S. CDC announced health screenings at three major airports for passengers arriving on flights from Wuhan.

In the early hours of January 18, the Wuhan health commission resumed public notices about the outbreak, announcing that in the 24 hours of January 16, four new cases of the coronavirus had been discovered. In the early morning of January 19, Wuhan City issued a notice saying that 17 patients had been found newly infected with the virus on January 17, raising the total number of confirmed cases to 62.

On January 18, Wuhan’s Baibuting neighborhood (百步亭社区) held a mass “10,000-family feast,” with 13,986 courses served in the Party-masses Events Center (党群活动中心) main events area and across nine secondary areas. Addressing the controversy that this event created for Baitbuting, Wuhan mayor Zhou Xianwang (周先旺) said that “The reason why we continued to hold this event this year is based on our previous judgment that the spread of the epidemic had only limited transmission between people, so there was not enough warning about this. “

Research Race

A race for scientific research began when the first team of experts from the National Health Commission arrived in Wuhan on December 31. At 10 p.m. on December 30, the team of Shi Zhengli (石正丽) — director of the Research Center for Emerging Infectious Diseases at Wuhan’s Institute of Virology — was commissioned by the Wuhan CDC to test samples from several patients. On January 2, they sequenced the entire genome for the virus, confirming it to be a novel coronavirus. On January 5, the virus was successfully isolated and obtained, and Shi made her team’s findings available to the WHO as instructed by the NHC.

As this was happening, on December 26, 2019, the team led by Zhang Yongzhen (张永振), a virology expert from the China Centers for Disease Control and Prevention of Infectious Diseases and an adjunct professor at the Shanghai Public Health Clinical Center of Fudan University, received a sample provided by the Wuhan Central Hospital and the Wuhan municipal CDC from a patient suffering from a fever of unknown cause. In the morning of January 5, the Center discovered in the sample a novel coronavirus, and found the pathogen’s entire genome sequence using high-throughput sequencing. The findings were publicized on January 10.

Regardless of who won this “race” for separating the virus, Chinese scientists were able to sample and sequence the pathogen and make this knowledge public to the rest of the world in a very short time compared to the situation during the SARS epidemic, when mistakes made in determining the pathogen led to significant delays. The Chinese efforts were uniformly praised in the international community, which saw the success as a good start to controlling the outbreak.

After the data of the novel coronavirus was publicized, a “thesis race” among Chinese scientists commenced. On January 21, two Chinese elite Chinese universities “in a race to publish theses” clashed with each other. The Gao Shan Scientific Research Team (高山科研组) of Nankai University published its “Bioinformational Analysis of the Wuhan 2019 Coronavirus Sequence” in a major Chinese language periodical “Bioinformatics” (生物信息学). This drew accusations from Fudan University’s Zhang Yongzhen, who claimed that the periodical had used and published the figures that he produced without his consent. Gao Shan responded by saying that since the data had been made public, it was no longer subject to copyright restrictions and could be used by others.

What really caused a stir among the public was a January 29 article, published in the New England Journal of Medicine and co-authored by Feng Zijian (冯子健), deputy director of the China CDC; Yang Bo (杨波), director of the Hubei CDC; and Gao Fu (高福), director of the China CDC and Chinese Academy of Sciences.

In an analysis of 425 coronavirus patients as of January 22, the article found that 55% of the cases that occurred before January 1, 2020 were related to the Huanan Seafood Market, whereas only 8.6% of the cases that occurred after the new year were. In response, Wang Liming (王立铭), a professor at Zhejiang University, said on Weibo that “from this article, it can be seen that the national CDC already had clear evidence of human-to-human transmission as early as the first days of January … so at which juncture was this information covered up?”^[4]

In the span of just two hours, Wang Liming’s question was reposted and commented on by tens of thousands of netizens. Gao Fu and the China CDC suddenly faced a crisis of public trust. Some pointed out that Gao Fu was a virologist, and as such, lacked experience in epidemic prevention and public health.

In response, China CDC deputy director Feng Zijian explained on January 31 that the authors obtained the data on January 23 and did a retrospective analysis, and that all of the cases had been made public before the paper’s drafting.

Eric Rubin, editor-in-chief of the New England Journal of Medicine and director of the Department of Immunity and Infectious Diseases at Harvard University’s School of Public Health, said that the paper took only 48 hours from submission to publication. Gao Fu told China News Weekly: “I just want to find a way to suppress the epidemic, there’s nothing else I want to say. Many people move from one extreme to the other. What should I say? I’ll just do my job.”

In fact, prior to the publication of the paper by Gao Fu et al., several papers had discussed the possibility of the outbreak spreading. On January 24, a paper published in The Lancet by Huang Chaolin (黄朝林), deputy director of Jinyintan Hospital, a designated hospital for the new coronary pneumonia in Wuhan, pointed out that 14 of the first 41 cases in Wuhan had no history of exposure to the Huanan Seafood Market, which meant that the market was not the only source of the outbreak. The paper stated that the first infection in Wuhan Jinyintan Hospital dates back to December 1, 2019, and that this case did not involve exposure to the Huanan Seafood Market.

This means that humans first contracted the virus as early as November last year, and spread it until there was a concentrated outbreak at the Huanan Seafood Market in December.

Incomplete statistics show that as of the end of January, Chinese scientists have published a total of six articles in The Lancet and the New England Journal of Medicine about the Wuhan coronary pneumonia. Zuo-Feng Zhang said that the scientific research results of Wuhan pneumonia were first-class and articles were published in many well-known magazines in a short period of time.

On January 30, the Ministry of Science and Technology stated that “each project undertaker and its scientific researchers must first adhere to the interests of the nation and the people, write their papers ‘on the motherland’, and apply their research results to the prevention and control of the outbreak. Until the epidemic prevention and control mission is completed, they should not focus on publishing their papers.”

In practice, judging from early developments in the outbreak, these instructive research data and conclusions were not disclosed to the Chinese public, nor were they applied to fighting the outbreak in a timely manner. Where exactly the government went wrong in its decision making process is still a matter of mystery.

The Role of the China CDC

Just as blurry is the role of the Chinese disease control and prevention organs in the decision making process.

The monitoring system for infectious diseases was rebuilt in 2004 after the SARS had exposed the major problems it had. Ms. Yang Gonghuan (杨功焕), retired former deputy director of China Center for Disease Control and Prevention told China News Weekly that China CDC built an online direct reporting system that horizontally covers all parts of China and vertically connects all the way to computers of township health clinics. When a case of infectious disease, including atypical pneumonia, is discovered, hospitals must report the case directly in this system, and China CDC on all levels can be aware of it instantly. China CDC has a group of people whose job is to monitor the system and write an analysis report every day. Once there are more than 5 cases of atypical pneumonia in one locale, a verification mechanism will be triggered automatically: China CDC will send people to conduct an epidemiological investigation, visiting patients and collecting samples.

Yang Gonghuan stressed that this reporting system is not hierarchical; China CDC in Beijing sees the case report as soon as a hospital reports it in the system. “Anywhere across China, even on the lowest level, as long as a case is reported, even if it’s just one case, we at China CDC can see it in the system.”

In Wuhan, the current epidemic is a new infectious disease caused by a new virus. Former director of China CDC Li Liming told China News Weekly that China amended “The Law on the Prevention and Treatment of Infectious Disease” on December 1, 2004. In Class B infectious diseases it added “infectious atypical pneumonia” but stipulated the same level of response as that to Category A diseases^[5]. In addition, the amended law requires that “outbreak of other infectious diseases and spread, or sudden outbreak of unidentifiable infectious diseases must be reported to higher authorities.”

But real time monitoring by disease control organs doesn’t necessarily mean making timely announcements and timely decisions. According to The Law on the Prevention and Treatment of Infectious Disease, “the health administrative department under the State Council shall be responsible for announcing information about the infectious disease when there is an outbreak and an epidemic.”^[6]

Regarding epidemic disclosure, Zeng Guang (曾光), the chief epidemiologist of China CDC told China News Weekly that the China CDC “has only the right to work,” it can collect and analyze data, but it is not a decision making agency. By comparison, the CDC in the U. S. is a government entity with administration power while China CDC has no such power. In China’s health system, the China CDC is absolutely weak, and it can discuss epidemics only when the government authorizes it to do so. The China CDC is mainly a technical entity; with regard to the control and prevention of epidemics, it can only make recommendations, not decisions.^[7]

Huang Yanzhong (黄严忠), professor and director of global health studies at Seton Hall University’s School of Diplomacy and International Relations, and a senior fellow for global health at the Council on Foreign Relations, told China News Weekly that the China CDC is an entity under the National Health Commission (NHC), and serves as more of a technical and supporting unit. Even though it is a top-down system reaching all the way to county level, it has limited power, and it has no power to publicize information about epidemics. On the other hand, while the American CDC is part of the Department of Health and Human Services, it has considerable independence, including the power to disclosing epidemics and taking measures to respond to them.

Zhong Nanshan Arrives in Wuhan

January 20 was a turning point. On this day, the Wuhan Municipal Health Commission updated the data of the two previous days: on the 18^th and the 19^th, there were 136 new cases diagnosed. For the first time, Wuhan health commission’s announcement removed previous statements that “limited person-to-person transmission cannot be ruled out,” and that “the risk of continuous person-to-person transmission is relatively low.”

The group of senior experts sent by the NHC and headed by Zhong Nanshan (钟南山), a member of China Engineering Academy, arrived in Wuhan on January 19 to investigate the epidemic and direct the control and prevention effort. In the evening of January 20, Zhong Nanshan appeared on CCTV’s “News 1+1” live interview, confirming that the novel coronavirus can be spread person to person, and that 14 health workers were infected while giving care to a single patient.

The news ignited a public outrage. The following day on January 21, Wuhan Health Commission announced that 15 health workers in Wuhan had been infected, and one was suspected of infection.^[8]

According to a China CDC chart that was apparently taken at an internal meeting on or around February 4 and leaked to social media (two sources from two different venues leaked the same chart), by January 20, 501 health workers in 13 hospitals in Wuhan were diagnosed 2019-nConV infection and 600 more were suspected. The total is 1,101, not including hospitals with fewer than 15 cases of health worker infections.

Also on January 21, Wuhan mayor Zhou Xianwang (周先旺) told CCTV that the health workers’ infection occurred at the Union Hospital during treatment of a patient in the Brain Surgery Department. “The brain surgery department wasn’t aware (忽视) that he had the coronavirus infection before he was admitted to the hospital. After the surgery he began to have a fever. At that point one doctor and 13 nurses had been infected.”

However, a neurosurgeon at the Union Hospital responded to the mayor on social media, saying “there is no such thing as ‘not being aware’!”

The 69-year-old Zhao Junshi (赵军实, an alias) with a pituitary tumor is the patient the Wuhan mayor was referring to, and he had had no contact with the Huanan wet market. In December 2019,^[9] he was admitted to Wuhan Union Hospital’s neurosurgery department. Before surgery, the doctors didn’t detect any respiratory symptoms. “He has a history of smoking, and it’s normal that he had lung inflammation or signs of thickening in his lungs. So there was almost no reason to believe that the patient needed to be quarantined, or that doctors and nurses needed to take the Grade Three protection, usually required only when performing tracheostomies.

The surgery was conducted on January 7, 2020. Following the surgery, Zhao Junshi changed wards four times. The third day after surgery he had a lung infection, and on the fifth day he was considered to have “what looks like pneumonia of unknown cause.” Health workers who had had contact with him began to catch fevers. On January 15, Zhao Junshi was diagnosed with coronavirus infection.

In the process, 10 nurses at the neurosurgery department and four in the pediatric surgery, gynecology, cardiac surgery, and cardiology departments were infected. By January 19, the Union Hospital’s Physical Examination Center (体检中心) was repurposed for “infectious wards.” On the fourth floor the hospital set up quarantine rooms for health workers suspected of having been infected. At the peak, more than 20 were suspected. Dr. Li Wenliang began to have fever and nausea 10 days after he was reprimanded for spreading misinformation. On January 14 he was hospitalized in the quarantined wards in the respiratory department, and was confirmed on February 1 to have been infected.

On January 20, for the first time, Communist Party general secretary Xi Jinping gave important instructions on the coronavirus epidemic. On that day, the State Council approved to list the novel coronavirus pneumonia as a Category Two infectious disease — the same as SARS — but take the highest level of control and prevention measures, those used for plague and cholera. At the time, the experts’ assessment of the epidemic remained “preventable and controllable.”

By then, starting approximately 10 days earlier on January 10, the annual Chinese New Year migration had begun. On January 20, Shanghai, Beijing, and Guangdong also identified, respectively, 1, 5 and 14 cases of the novel coronavirus pneumonia. It was also the first time other provinces had announced the epidemic. Almost all these cases were imported cases with a recent history of traveling to or living in Wuhan, or having had close contact with a patient. Beginning January 21, the NHC began daily announcements of new cases nationwide.

While the number of infections was climbing up rapidly and the disease had spread to other parts of the country, in Wuhan, activities involving large numbers of people went on as planned. In the afternoon of January 20, the Hubei provincial Department of Emergency Response Management (湖北省应急管理厅) actually held a Spring Festival gala with the theme “use sweat to irrigate the harvest, work hard to move forward steadfastly.”

On January 21, the provincial government’s Spring Festival celebration gala was held in Wuhan Hongshan auditorium where the provincial party secretary Jiang Chaoliang (蒋超良), the provincial governor Wang Xiaodong (王晓东) and representatives from all sectors across the province watched songs and dances. According to the social media account of Hubei province Ethnic Song and Dance Ensemble, more than 40 performers of the ensemble took part in the festivity. “In Wuhan, wearing layers of mask and overcoming panic, everyone performed with professionalism and dedication. …In Xiaogan (孝感), performers carried on the performance with the same ardent even though some were shivering with fever.”

On January 21, Wuhan Health Commission issued two more announcements of 258 cases of coronavirus infections by midnight January 20. In the evening of the 22nd, the Wuhan municipal government required residents to wear masks in public.

In the early morning of January 22, Hubei Province suddenly initiated a second-degree public health emergency response. By comparison, the next day, Guangdong Province went straight to a first-degree public health emergency.

In a January 31 interview with CCTV, Wuhan Party secretary Ma Guoqiang (马国强) said, “I have been thinking that it would probably be better if we could have taken measures sooner, for example, when we began to take temperatures on January 12 or 13, whether we should have restricted flights, high speed train, buses, and boats from leaving Wuhan at that time, as we did starting the 23rd. If we had taken action then, the epidemic might have been mitigated somewhat, and not be as bad as it is now. Right now I feel ashamed and guilty. If we had taken more stringent control measures sooner, the outcome would have been better, and the impact on other parts of the country would have been less. We would have also alleviated the worries of Party central and the State Council.”

In the small hours of January 23, the Wuhan government issued the order to “lock down” the city. But three days later, on January 26, the mayor said that by then five million had left the city for the New Year holiday or to escape the epidemic.

Notes:

^[1] The police’s Note of Reprimandation reads, “We hope you will calm down and reflect carefully. We solemnly warn you that you will be punished by the law if you don’t repent, if you continue to hold on to your stubborn belief and continue engaging in illegal activities.” Li Wenliang put his answer “Understood (明白)” on the Note, authenticating it with a fingerprint. On January 10, he began to run a fever and cough, and on January 12 he was hospitalized. It wasn’t until February 1 when he was diagnosed with coronavirus infection. His parents were infected too. Dr. Li Wenliang died the night of February 6 at the age of 34. He and his wife have a 5-year-old and his wife is six months pregnant.

^[2] The Union Hospital is the largest hospital in Wuhan.

^[3] While doctors in Wuhan hospitals were gagged, starting January 3, China has communicated with the U. S. some 30 times, according to MFA Hua Chunying (华春莹). The U. S. offered three times, the earliest on January 6, to send experts to China to help combat the coronavirus but China declined until January 29, when it agreed to allow American experts to join a WHO delegation to China.

^[4] Again, the United States was first notified of the novel coronavirus pneumonia on January 3.

^[5] Class A infectious diseases, according to the law, are plague and cholera.

^[6] What happened to the disclosure of the 2019-nConV? The health administrative organ under the State Council is the National Health Commission (国家卫生健康委员会) headed by Ma Xiaowei (马晓伟), and the vice-premier in charge of health is Sun Chunlan (孙春兰).

^[7] The Wuhan mayor and the chief epidemiologist at ChinaCDC shed some light on decision making and authorization in the first weeks of the epidemic. Mayor Zhou Xianwang said in a CCTV interview on January 27 that “the public is not satisfied with our information disclosure. It was not timely on the one hand, and on the other our response didn’t meet the bar with what the information we had. With regard to the tardiness of disclosure, I hope everyone understands that this is an infectious disease, and disclosure is governed by the Law on the Prevention and Treatment of Infectious Disease. As a local government official, I receive the information, but I can’t disclose it without authorization. This was not understood at the time. On January 29 China CDC chief epidemiologist Zeng Guang said in an interview with the Global Times that the slow response to the epidemic is partly due to the process of scientific understanding, but the hesitation of decision makers and the lack of confidence also plays a role. Zeng Guang said that public health professionals approach the matter from a scientific point of view. But when making decisions, government officials would not only consider the scientific aspect. “He has to consider the political aspect, consider stability maintenance, consider economy; he also considers the population’s enjoyment of the Chinese New Year, and the popular satisfaction. What we say is often only partially adopted. Zeng added that, “I’m not saying that government officials’ approach is wrong; decision making does have to take into consideration many aspects. But on crucial matters we have to establish an experience, and we have to adopt a more scientific point of view. If we don’t, other considerations will be meaningless.”

^[8] According to a China CDC chart that was apparently taken at an internal meeting on or around February 4 and leaked to social media (two sources from two different venues leaked the same chart), by January 20, 501 health workers in 13 hospitals in Wuhan were diagnosed 2019-nConV infection and 600 more were suspected. The total is 1,101, not including hospitals with fewer than 15 cases of health worker infections.

^[9] What date in December?

Going Around Coronavirus-Stricken Wuhan With Fang Bin, Visiting Hospitals, and Being Visited by Police, on February 1, 2020, China Change, Feb 3, 2020.